Provider Demographics
NPI:1700696309
Name:HEIDISH, JACOB (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:HEIDISH
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5040 FOREST DR STE 300
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-8166
Practice Address - Country:US
Practice Address - Phone:614-890-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-07
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.009220RX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical