Healthcare Provider Details

I. General information

NPI: 1720209075
Provider Name (Legal Business Name): LEE R JACOBSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 OAK ST E
FREDERIC WI
54837-9574
US

IV. Provider business mailing address

PO BOX 630
FREDERIC WI
54837-0630
US

V. Phone/Fax

Practice location:
  • Phone: 715-327-8239
  • Fax: 715-327-8252
Mailing address:
  • Phone: 715-327-8239
  • Fax: 715-327-8252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER JACOBSON TURCOTT
Title or Position: OWNER
Credential: O.D.
Phone: 715-327-8239