Healthcare Provider Details

I. General information

NPI: 1952163982
Provider Name (Legal Business Name): JACOB HAUSCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E WALNUT ST
LANCASTER OH
43130-4464
US

IV. Provider business mailing address

220 E WALNUT ST
LANCASTER OH
43130-4464
US

V. Phone/Fax

Practice location:
  • Phone: 740-277-6043
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008607RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: