Individual
KENNETH LEE DINE JACOBS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
2615 E HIGH ST, SPRINGFIELD, OH 45505-1412
(937) 325-0531
Mailing address
3131 NEWMARK DR STE 210, MIAMISBURG, OH 45342-5400
(937) 438-8910
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
34.005854
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000017441
ANTHEM
OH
05
—
0986116
—
OH
Enumeration date
04/13/2006
Last updated
07/27/2020
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