Provider Demographics
NPI:1902210404
Name:JACOBS, BRYAN JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:JOHN
Last Name:JACOBS
Suffix:
Gender:
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:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:937-641-6129
Practice Address - Street 1:3333 W TECH RD STE 220
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-0956
Practice Address - Country:US
Practice Address - Phone:937-885-4475
Practice Address - Fax:937-885-3670
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE29116208000000X
OH35.151519208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121663Medicaid