Healthcare Provider Details

I. General information

NPI: 1821712316
Provider Name (Legal Business Name): JACOB DOUGHERTY AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MIAMI VALLEY DR
CENTERVILLE OH
45459-4774
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-438-2400
  • Fax:
Mailing address:
  • Phone: 937-762-1306
  • Fax: 937-522-7017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0032076
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: