Provider Demographics
NPI:1770130858
Name:REDFOX, JACOB MICHAEL DAKOTA (PA-C)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:MICHAEL DAKOTA
Last Name:REDFOX
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:471 E BROAD ST STE 1400
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3806
Mailing Address - Country:US
Mailing Address - Phone:614-228-7231
Mailing Address - Fax:
Practice Address - Street 1:7610 TOURNAMENT DR
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-8702
Practice Address - Country:US
Practice Address - Phone:419-704-6634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009468363A00000X
OH50.006018RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant