Provider Demographics
NPI:1508392465
Name:PRAY, JAKE (OD)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:PRAY
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 1:2111 BEASER AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3608
Mailing Address - Country:US
Mailing Address - Phone:715-682-0363
Mailing Address - Fax:715-682-9638
Practice Address - Street 1:2111 BEASER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3608
Practice Address - Country:US
Practice Address - Phone:715-682-0363
Practice Address - Fax:715-682-9638
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12345152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist