Provider Demographics
NPI:1124023809
Name:JACOBS, MARK A (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:JACOBS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:KY
Mailing Address - Zip Code:42533-0306
Mailing Address - Country:US
Mailing Address - Phone:606-492-2211
Mailing Address - Fax:606-676-0873
Practice Address - Street 1:3810 S HIGHWAY 27
Practice Address - Street 2:SUITE 1
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-3073
Practice Address - Country:US
Practice Address - Phone:606-678-4551
Practice Address - Fax:606-678-0972
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1201DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY410028407OtherRAILROAD MEDICARE
KY380000269OtherRAILROAD MEDICARE
KY7100209960Medicaid
127554OtherBCBSTN/BLUECARE/TENNCARE
TN4599154Medicaid
KY7100209970Medicaid
00160523OtherAMERIGROUP
KY77012011Medicaid
KY77012011Medicaid
KY0487990006Medicare NSC
KY380000269OtherRAILROAD MEDICARE
KY0241603Medicare PIN
TN4599154Medicaid
KY0096603Medicare PIN