Provider Demographics
NPI:1801312616
Name:JACOBS, DENISA DESPINA (RT (R)(CT), PA-C)
Entity type:Individual
Prefix:MRS
First Name:DENISA
Middle Name:DESPINA
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RT (R)(CT), PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:425 W GRAND AVE STE 2002
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4722
Practice Address - Country:US
Practice Address - Phone:937-425-4144
Practice Address - Fax:937-425-4146
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHR88619232471C3401X, 2471C3402X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
1132364OtherNCCPA