Provider Demographics
NPI:1447447503
Name:SHORT, JACOB M (PAC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:M
Last Name:SHORT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 US RT 60 EAST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705
Mailing Address - Country:US
Mailing Address - Phone:304-528-4600
Mailing Address - Fax:304-733-3143
Practice Address - Street 1:5170 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2004
Practice Address - Country:US
Practice Address - Phone:304-528-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1310363A00000X
WVWV1310207Y00000X
WV01310363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1447447503Medicaid
OH0356376Medicaid
KY7100109200Medicaid