Healthcare Provider Details

I. General information

NPI: 1992741441
Provider Name (Legal Business Name): JACOB THOMAS JANECEK O.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 NW 169TH PL
BEAVERTON OR
97006-7310
US

IV. Provider business mailing address

17430 NW SOLANO LN
PORTLAND OR
97229-2239
US

V. Phone/Fax

Practice location:
  • Phone: 503-533-8441
  • Fax: 503-533-8403
Mailing address:
  • Phone: 503-533-8441
  • Fax: 503-533-8403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2877AT
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2877AT
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2877AT
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2877AT
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: