Jacob D Bly

Primary specialty

Psychiatry PhysicianTaxonomy code 2084P0800X

License

2025044588 Issued in MO

Practice address

4755 Olgetown Staton Rd
Newark, DE 19718-0001

Phone

(302) 733-1043

NPI assigned

Apr 13, 2021

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MO

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Psychiatry

Education

University of Missouri, Kansas City, School of Medicine, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

SSM Regional Health ServicesGroup PAC ID 8921917352, shared by 13 NPIs, 165 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mosaic Medical Center - Maryville

  • Specialist
  • Maryville, MO
  • NPI 1184189797

  MO, Psychiatry

  Medicare reassignment NPD
• Mosaic Medical Center - Maryville

  • Psychiatric Hospital Unit
  • Maryville, MO
  • NPI 1477027803
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1618272000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1763337600000",
    "number": "1972183846",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4755 OLGETOWN STATON RD",
            "city": "NEWARK",
            "state": "DE",
            "postal_code": "197180001",
            "telephone_number": "302-733-1043"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4755 OLGETOWN STATON RD",
            "city": "NEWARK",
            "state": "DE",
            "postal_code": "197180001",
            "telephone_number": "302-733-1043"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "114 E South Hills Dr",
            "address_purpose": "LOCATION",
            "city": "Maryville",
            "state": "MO",
            "postal_code": "644682659",
            "country_code": "US",
            "telephone_number": "660-562-4305",
            "fax_number": "660-562-4315",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BLY",
        "first_name": "JACOB",
        "middle_name": "D",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2021-04-13",
        "last_updated": "2025-11-17",
        "certification_date": "2025-11-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "MO",
            "license": "2025044588",
            "primary": true
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Blue Hen Physical Therapy, Inc.
• Blue Hen Physical Therapy, Inc.
• Blue Hen Physical Therapy, Inc.
• Joseph Blue
• Susan N. Bluhm, ACNP
• Janice E Boc, NNP
• Alex B Bodenstab, MD
• Ann Marie Bodi, NNP
• Charles R Bodine
• Body Brain Sync, Inc

• Psychiatry Physician in Newark, DE
• Providers in Newark, DE by specialty
• Psychiatry Physician in Delaware

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 17, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.