Provider Demographics
NPI:1326787763
Name:JENNESS, JACOB RAY (OD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:RAY
Last Name:JENNESS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2312 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-1044
Mailing Address - Country:US
Mailing Address - Phone:712-336-1960
Mailing Address - Fax:952-567-6176
Practice Address - Street 1:9801 DUPONT AVE S STE 200
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3200
Practice Address - Country:US
Practice Address - Phone:952-888-5800
Practice Address - Fax:952-567-6156
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN3793152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist