Provider Demographics
NPI:1689246597
Name:SANDERS, JACOB A
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:SANDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 329
Mailing Address - Street 2:
Mailing Address - City:PAULDING
Mailing Address - State:OH
Mailing Address - Zip Code:45879-0329
Mailing Address - Country:US
Mailing Address - Phone:419-399-3636
Mailing Address - Fax:
Practice Address - Street 1:501 MC DONALD PIKE
Practice Address - Street 2:
Practice Address - City:PAULDING
Practice Address - State:OH
Practice Address - Zip Code:45879-9239
Practice Address - Country:US
Practice Address - Phone:419-399-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002576175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist