=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447870258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB OLIVER WEBER OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2020
-----------------------------------------------------
Last Update Date | 09/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 O ST STE A
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68510-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-475-9113
-----------------------------------------------------
Fax | 402-475-8084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 N MAIN ST
-----------------------------------------------------
City | DENISON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51442-1373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-263-2020
-----------------------------------------------------
Fax | 712-263-4053
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 099902
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1533
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------