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General NPI Number Information
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NPI Number | 1124023809
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Entity Type | Individual
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Provider Name | MARK A JACOBS O.D.
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Gender | Male
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Dates
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Enumeration Date | 06/17/2005
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Last Update Date | 12/03/2019
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Provider Practice Location Address
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Address Line | 3810 S HIGHWAY 27 SUITE 1
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City | SOMERSET
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State | KY
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Zip | 42501-3073
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Country | US
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Telephone | 606-678-4551
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Fax | 606-678-0972
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Provider Business Mailing Address
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Address Line | PO BOX 306
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City | FERGUSON
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State | KY
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Zip | 42533-0306
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Country | US
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Telephone | 606-492-2211
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Fax | 606-676-0873
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1201DT
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License Number State | KY
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