Provider Demographics
NPI:1114009982
Name:JACOBSON, WILLIAM JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JAY
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:245 BLOOMFIELD DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-7788
Mailing Address - Country:US
Mailing Address - Phone:717-517-7190
Mailing Address - Fax:717-517-7379
Practice Address - Street 1:245 BLOOMFIELD DR
Practice Address - Street 2:SUITE 108
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-7788
Practice Address - Country:US
Practice Address - Phone:717-517-7190
Practice Address - Fax:717-517-7379
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002450152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
397572OtherNATIONAL VISION ADMIN
5211416OtherAETNA
5211416OtherAETNA
397572OtherNATIONAL VISION ADMIN