Provider Demographics
NPI:1497095244
Name:BAILEY, JACOB SHUMWAY (OD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SHUMWAY
Last Name:BAILEY
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 1:2043 COLLEGE WAY
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1756
Mailing Address - Country:US
Mailing Address - Phone:503-858-0991
Mailing Address - Fax:
Practice Address - Street 1:1124 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6414
Practice Address - Country:US
Practice Address - Phone:575-434-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXODP-100283152W00000X
NM697152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist