Healthcare Provider Details

I. General information

NPI: 1639659949
Provider Name (Legal Business Name): JACOB REED BOWEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2282 E PINETREE BLVD
THOMASVILLE GA
31792-4807
US

IV. Provider business mailing address

2282 E PINETREE BLVD
THOMASVILLE GA
31792-4807
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-6000
  • Fax: 229-226-5859
Mailing address:
  • Phone: 229-226-6000
  • Fax: 229-226-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2793
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003278
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2053-IOD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: