Provider Demographics
NPI:1063611853
Name:JACOBS, LIESL JADE (MD)
Entity type:Individual
Prefix:
First Name:LIESL
Middle Name:JADE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3794
Mailing Address - Country:US
Mailing Address - Phone:937-752-2310
Mailing Address - Fax:937-522-8493
Practice Address - Street 1:5350 LAMME RD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-3215
Practice Address - Country:US
Practice Address - Phone:937-534-4651
Practice Address - Fax:937-534-4669
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0976032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067987Medicaid
OHQMP000004762758OtherMOLINA
OH000000915098OtherANTHEM
OH000000915098OtherANTHEM
OHQMP000004762758OtherMOLINA