Provider Demographics
NPI:1124388525
Name:HANNON, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 NC HIGHWAY 14
Mailing Address - Street 2:APT A-2
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-9666
Mailing Address - Country:US
Mailing Address - Phone:307-272-6875
Mailing Address - Fax:
Practice Address - Street 1:2814 KENT AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-8250
Practice Address - Country:US
Practice Address - Phone:307-272-2716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0618002148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program