Healthcare Provider Details

I. General information

NPI: 1952716276
Provider Name (Legal Business Name): JACOB COLLIE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
DAYTON OH
45433-5529
US

IV. Provider business mailing address

5301 VIRGINIA WAY STE 300
BRENTWOOD TN
37027-7542
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-2785
  • Fax:
Mailing address:
  • Phone: 615-221-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number1412
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number5249
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0102207658
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1412
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: