Provider Demographics
NPI:1558714840
Name:HEATH, JACOB (OD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HEATH
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 1:1200 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:618-969-8777
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:1207 N ONE MILE RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1041
Practice Address - Country:US
Practice Address - Phone:573-624-4584
Practice Address - Fax:573-624-4992
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016023867152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist