Provider Demographics
NPI:1508885369
Name:IVEY, JACOB A (OD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:A
Last Name:IVEY
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 1:14994 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-2616
Mailing Address - Country:US
Mailing Address - Phone:662-773-3494
Mailing Address - Fax:
Practice Address - Street 1:14994 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2616
Practice Address - Country:US
Practice Address - Phone:662-773-3494
Practice Address - Fax:662-773-7883
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPENDING152W00000X
MS762152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09351503Medicaid
MSV10965Medicare UPIN
MS1242340001Medicare NSC
MS410000390Medicare PIN