Provider Demographics
NPI:1376535948
Name:JACOBS, JON STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:STEPHEN
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 1:2419 E COMMERCIAL BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4042
Mailing Address - Country:US
Mailing Address - Phone:954-771-9120
Mailing Address - Fax:954-581-5496
Practice Address - Street 1:2419 E COMMERCIAL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308
Practice Address - Country:US
Practice Address - Phone:954-771-9120
Practice Address - Fax:954-771-4883
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC0000951152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084148000Medicaid
FL410002611Medicare PIN
FL19469YMedicare PIN
FL084148000Medicaid
FLDP8124Medicare PIN
T83988Medicare UPIN
FLP01042720Medicare PIN
FL19469ZMedicare PIN
FL110087157Medicare PIN
FLDS5706Medicare PIN