MEDICARE: JUSTINA MARIE JACOB OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC005903	FL
2	152W00000X	Optometrist	OPC5903	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972165058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTINA MARIE JACOB OD

Provider Business Mailing Address
First Line	:	1225 W BAY DR
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33770-2203
Country	:	US
Telephone Number	:	727-581-8706
Fax Number	:

Provider Business Practice Location Address
First Line	:	11925 SHELDON RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-3644
Country	:	US
Telephone Number	:	727-581-8760
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2019
Last Update Date	:	02/14/2022

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