Provider Demographics
NPI:1255804795
Name:JACOBY, KATHLENE (APRN)
Entity type:Individual
Prefix:
First Name:KATHLENE
Middle Name:
Last Name:JACOBY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8720 STONECREEK CIR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3219
Mailing Address - Country:US
Mailing Address - Phone:937-825-9825
Mailing Address - Fax:
Practice Address - Street 1:7700 WASHINGTON VILLAGE DR STE 230
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4094
Practice Address - Country:US
Practice Address - Phone:937-438-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily