Provider Demographics
NPI:1285698670
Name:JACOBS, KENNETH LEE DINE (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE DINE
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 NEWMARK DR STE 210
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5400
Mailing Address - Country:US
Mailing Address - Phone:937-438-8910
Mailing Address - Fax:
Practice Address - Street 1:2615 E HIGH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1412
Practice Address - Country:US
Practice Address - Phone:937-325-0531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.005854207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0986116Medicaid
OH000000017441OtherANTHEM
OH930066377Medicare PIN
OH0986116Medicaid
OHF79315Medicare UPIN