Provider Demographics
NPI:1275263105
Name:JACOBS, LACEY
Entity Type:Individual
Prefix:DR
First Name:LACEY
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4172 BUCKEYE PKWY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-8175
Mailing Address - Country:US
Mailing Address - Phone:614-782-9048
Mailing Address - Fax:
Practice Address - Street 1:4172 BUCKEYE PKWY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-8175
Practice Address - Country:US
Practice Address - Phone:614-782-9048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007078152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist