MEDICARE: DR. TODD MICHAEL JACOBS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	10394	KY

General Provider Information

NPI Number	:	1265827588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TODD MICHAEL JACOBS DMD

Provider Business Mailing Address
First Line	:	406 SHANNON DR
Second Line	:
City	:	EDGEWOOD
State	:	KY
Zip	:	41017-3353
Country	:	US
Telephone Number	:	859-394-2899
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 ALBERT SABIN WAY
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45267-2800
Country	:	US
Telephone Number	:	859-394-2899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2015
Last Update Date	:	03/07/2022

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