Healthcare Provider Details

I. General information

NPI: 1164476354
Provider Name (Legal Business Name): J A K ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3287 COURT ST
PEKIN IL
61554-6208
US

IV. Provider business mailing address

8309 N KNOXVILLE AVE
PEORIA IL
61615-2170
US

V. Phone/Fax

Practice location:
  • Phone: 309-353-9313
  • Fax: 309-353-4962
Mailing address:
  • Phone: 309-693-9540
  • Fax: 309-693-9542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DIANA J HALL
Title or Position: PRESIDENT
Credential:
Phone: 309-693-9540