MEDICARE: MRS. DENISA DESPINA JACOBS RT (R)(CT), PA-C

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	363A00000X	Physician Assistant	50.005271RX	OH
2	2471C3402X	Radiography Radiologic Technologist	R8861923	OH
3	2471C3401X	Computed Tomography Radiologic Technologist	R8861923	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1132364	OTHER		NCCPA

General Provider Information

NPI Number	:	1801312616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DENISA DESPINA JACOBS RT (R)(CT), PA-C

Provider Business Mailing Address
First Line	:	1 PRESTIGE PL STE 550
Second Line	:
City	:	MIAMISBURG
State	:	OH
Zip	:	45342-6115
Country	:	US
Telephone Number	:	937-762-1310
Fax Number	:	937-522-8068

Provider Business Practice Location Address
First Line	:	7700 WASHINGTON VILLAGE DR STE 120
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-4071
Country	:	US
Telephone Number	:	937-425-4144
Fax Number	:	937-425-4146

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

Provider Enumeration Date	:	08/15/2017
Last Update Date	:	03/05/2026

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