Provider Demographics
NPI:1861821191
Name:BLOUGH, JACOB A (RN)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:A
Last Name:BLOUGH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:RITTMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44270-1209
Mailing Address - Country:US
Mailing Address - Phone:330-465-7384
Mailing Address - Fax:
Practice Address - Street 1:63 ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:RITTMAN
Practice Address - State:OH
Practice Address - Zip Code:44270-1209
Practice Address - Country:US
Practice Address - Phone:330-465-7384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.410758163WC0200X
OHAPRN.CRNA.0020166367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine