Healthcare Provider Details

I. General information

NPI: 1609490531
Provider Name (Legal Business Name): JACOB CONDITT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2020
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 W PETERSON AVE STE 401
CHICAGO IL
60659-3307
US

IV. Provider business mailing address

2712 MCDOUGALD ST
NEWPORT AR
72112-3014
US

V. Phone/Fax

Practice location:
  • Phone: 773-588-3090
  • Fax:
Mailing address:
  • Phone: 870-664-6632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11785522-9934
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011525
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: