Provider Demographics
NPI:1851175418
Name:SUMMERS, JACOB DANIEL
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:SUMMERS
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 1:53447 MUD RUN RD
Mailing Address - Street 2:
Mailing Address - City:SENECAVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43780-9656
Mailing Address - Country:US
Mailing Address - Phone:567-303-9967
Mailing Address - Fax:
Practice Address - Street 1:10400 BLACKLICK EASTERN RD
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-8235
Practice Address - Country:US
Practice Address - Phone:740-868-9362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0487170Medicaid