Healthcare Provider Details

I. General information

NPI: 1568213668
Provider Name (Legal Business Name): JACOB JOHN MANSFIELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 MDG, 4881 SUGAR MAPLE DRIVE
WRIGHT PATTERSON AFB OH
45433
US

IV. Provider business mailing address

88TH MEDICAL GROUP 4881 SUGAR MAPLE DRIVE
WRIGHT PATTERSON AFB OH
45433
US

V. Phone/Fax

Practice location:
  • Phone: 937-522-2778
  • Fax:
Mailing address:
  • Phone: 937-522-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number57.256586
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57.256586
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: