Provider Demographics
NPI:1568213668
Name:MANSFIELD, JACOB JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JOHN
Last Name:MANSFIELD
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 1:88TH MEDICAL GROUP
Mailing Address - Street 2:4881 SUGAR MAPLE DRIVE
Mailing Address - City:WRIGHT PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-522-2778
Mailing Address - Fax:
Practice Address - Street 1:88 MDG, 4881 SUGAR MAPLE DRIVE
Practice Address - Street 2:
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433
Practice Address - Country:US
Practice Address - Phone:937-522-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.256586171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider