Healthcare Provider Details

I. General information

NPI: 1447870258
Provider Name (Legal Business Name): JACOB OLIVER WEBER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 O ST STE A
LINCOLN NE
68510-1510
US

IV. Provider business mailing address

201 N MAIN ST
DENISON IA
51442-1373
US

V. Phone/Fax

Practice location:
  • Phone: 402-475-9113
  • Fax: 402-475-8084
Mailing address:
  • Phone: 712-263-2020
  • Fax: 712-263-4053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number099902
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1533
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: