Provider Demographics
NPI:1669776753
Name:FORD, JACINTA K (PA-C)
Entity type:Individual
Prefix:
First Name:JACINTA
Middle Name:K
Last Name:FORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4031 COLONEL GLENN HWY
Mailing Address - Street 2:SUITE 133
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2774
Mailing Address - Country:US
Mailing Address - Phone:855-232-0644
Mailing Address - Fax:888-546-0488
Practice Address - Street 1:4031 COLONEL GLENN HWY
Practice Address - Street 2:SUITE 133
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2774
Practice Address - Country:US
Practice Address - Phone:855-232-0644
Practice Address - Fax:888-546-0488
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003112363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067765Medicaid
OH0067765Medicaid