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General NPI Number Information
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NPI Number | 1255330676
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Entity Type | Individual
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Provider Name | EDWARD CORNELIOUS JACOBS M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/18/2005
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Last Update Date | 03/05/2015
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Provider Practice Location Address
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Address Line | 10 SOUTHMOOR CIR NW
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City | KETTERING
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State | OH
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Zip | 45429-2486
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Country | US
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Telephone | 937-294-1489
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Fax | 937-297-6468
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Provider Business Mailing Address
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Address Line | 1 PRESTIGE PL SUITE 550
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City | MIAMISBURG
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State | OH
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Zip | 45342-3794
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Country | US
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Telephone | 937-752-2305
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G16625
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 014971
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License Number State | ME
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 32702
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License Number State | MA
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Taxonomy #4
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 35-07-3367-J
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License Number State | OH
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Taxonomy #5
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 35073367
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License Number State | OH
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