Provider Demographics
NPI:1891360830
Name:BLEDSOE, JACOB (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6460 LURIA LN APT 2204
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-5850
Mailing Address - Country:US
Mailing Address - Phone:812-296-1111
Mailing Address - Fax:
Practice Address - Street 1:2109 HUGHES
Practice Address - Street 2:3RD FLOOR JOBST TOWER
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606
Practice Address - Country:US
Practice Address - Phone:419-291-8154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.016743207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program