Provider Demographics
NPI:1023431756
Name:JACOB, ANGELA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:JACOB
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:HILDEBRANDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 2017
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4454
Mailing Address - Fax:513-636-3928
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 2017
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229
Practice Address - Country:US
Practice Address - Phone:513-636-4454
Practice Address - Fax:513-636-3928
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant