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NPI Code Detail

MEDICARE: J A K ENTERPRISES INC

MEDICARE: J A K ENTERPRISES INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist
2332H00000XEyewear Supplier

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
17215175OTHERILBCBS
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1508856923
Entity Type Code : Organization
Provider Name (Legal Business Name) : J A K ENTERPRISES INC
Provider Business Mailing Address
First Line : 8309 N KNOXVILLE AVE
Second Line :
City : PEORIA
State : IL
Zip : 61615-2170
Country : US
Telephone Number : 309-693-9540
Fax Number :
Provider Business Practice Location Address
First Line : 8309 N KNOXVILLE AVE
Second Line :
City : PEORIA
State : IL
Zip : 61615-2170
Country : US
Telephone Number : 309-693-9540
Fax Number :
Authorized Official
Title or Position : PRESIDENT/OWNER
Name : MS. DIANA J HALL
Credential :
Telephone Number : 309-693-9540
Provider Enumeration Date : 10/26/2005
Last Update Date : 06/02/2026

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Directions to “J A K ENTERPRISES INC ” Practice Location

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