MEDICARE: JACOB DOUGHERTY AGACNP-BC

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	363LG0600X	Gerontology Nurse Practitioner	APRN.CNP.0032076	OH

General Provider Information

NPI Number	:	1821712316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB DOUGHERTY AGACNP-BC

Provider Business Mailing Address
First Line	:	1 PRESTIGE PL STE 550
Second Line	:
City	:	MIAMISBURG
State	:	OH
Zip	:	45342-6115
Country	:	US
Telephone Number	:	937-762-1306
Fax Number	:	937-522-7017

Provider Business Practice Location Address
First Line	:	2400 MIAMI VALLEY DR
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-4774
Country	:	US
Telephone Number	:	937-438-2400
Fax Number	:

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

Provider Enumeration Date	:	09/28/2022
Last Update Date	:	03/11/2026

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