Individual
LIESL JADE JACOBS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
5350 LAMME RD, MORAINE, OH 45439-3215
(937) 534-4651
(937) 534-4669
Mailing address
1 PRESTIGE PL, SUITE 550, MIAMISBURG, OH 45342-3794
(937) 752-2310
(937) 522-8493
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
35.097603
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000915098
ANTHEM
OH
05
—
0067987
—
OH
01
—
QMP000004762758
MOLINA
OH
Enumeration date
07/12/2007
Last updated
05/07/2015
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