Provider Demographics
NPI:1326871872
Name:KEILHOLZ, JACOB (ATC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KEILHOLZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6370 ASTOR PLACE DR APT 307
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-1178
Mailing Address - Country:US
Mailing Address - Phone:419-206-5528
Mailing Address - Fax:
Practice Address - Street 1:6955 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-8580
Practice Address - Country:US
Practice Address - Phone:614-566-3489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2000050719207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine