Provider Demographics
NPI:1356943492
Name:JACOBY, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:JACOBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 E SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CAREY
Mailing Address - State:OH
Mailing Address - Zip Code:43316-1232
Mailing Address - Country:US
Mailing Address - Phone:419-429-2233
Mailing Address - Fax:
Practice Address - Street 1:233 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:CAREY
Practice Address - State:OH
Practice Address - Zip Code:43316-1232
Practice Address - Country:US
Practice Address - Phone:419-429-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH105229875799Medicaid