Provider Demographics
NPI:1215721774
Name:CRUSE, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CRUSE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4531 BEAVER PIKE
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:OH
Mailing Address - Zip Code:45613-9300
Mailing Address - Country:US
Mailing Address - Phone:740-708-0435
Mailing Address - Fax:
Practice Address - Street 1:4461 STATE ROUTE 159 STE A
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-6000
Practice Address - Country:US
Practice Address - Phone:740-779-4900
Practice Address - Fax:740-779-4909
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.034882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine