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General NPI Number Information
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NPI Number | 1780412957
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Entity Type | Individual
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Provider Name | JACOB CARL YATES
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Gender | Male
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Dates
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Enumeration Date | 07/22/2024
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Last Update Date | 12/19/2024
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Provider Practice Location Address
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Address Line | 15 CYPRESS BRANCH WAY STE 205
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City | PALM COAST
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State | FL
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Zip | 32164-8414
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Country | US
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Telephone | 386-445-1880
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Fax |
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Provider Business Mailing Address
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Address Line | 8614 WESTWOOD CENTER DR FL 9
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City | VIENNA
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State | VA
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Zip | 22182-2442
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Country | US
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Telephone | 703-847-8899
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Fax |
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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 | 2416DT
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC6592
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License Number State | FL
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