Provider Demographics
NPI:1821712316
Name:DOUGHERTY, JACOB (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 COLUMBUS AVE UNIT 23
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-2688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 MIAMI VALLEY DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4774
Practice Address - Country:US
Practice Address - Phone:937-438-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0032076363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care