Healthcare Provider Details

I. General information

NPI: 1942801907
Provider Name (Legal Business Name): JACOB ANDREW BOEHME OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 MADISON AVE
MEMPHIS TN
38104-2211
US

IV. Provider business mailing address

1245 MADISON AVE
MEMPHIS TN
38104-2211
US

V. Phone/Fax

Practice location:
  • Phone: 901-722-3200
  • Fax:
Mailing address:
  • Phone: 901-722-3250
  • Fax: 901-722-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number3656
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number114718
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3656
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number114718
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: