Healthcare Provider Details

I. General information

NPI: 1124173521
Provider Name (Legal Business Name): KEVIN SEAN JACOB O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 FERGUSON BLVD
DRY RIDGE KY
41035-8635
US

IV. Provider business mailing address

9100 BRANTLEY WAY
FLORENCE KY
41042-8684
US

V. Phone/Fax

Practice location:
  • Phone: 859-824-1333
  • Fax:
Mailing address:
  • Phone: 859-384-7646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1458DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: