Provider Demographics
NPI:1104882976
Name:JACOBS, BRADLEY S (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E APPLE ST STE 5254A
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-4200
Mailing Address - Fax:937-208-4205
Practice Address - Street 1:30 E APPLE ST STE 5254A
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-4200
Practice Address - Fax:937-208-4205
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0864542084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2633823Medicaid
OHH184020Medicare PIN
OH2633823Medicaid
H15453Medicare UPIN