Provider Demographics
NPI:1629324918
Name:BURTON, JACOB (OD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:BURTON
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 1:301 BURKESVILLE STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-1921
Mailing Address - Country:US
Mailing Address - Phone:270-384-6043
Mailing Address - Fax:270-384-0672
Practice Address - Street 1:301 BURKESVILLE STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-1921
Practice Address - Country:US
Practice Address - Phone:270-384-6043
Practice Address - Fax:270-384-0672
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1893DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY1893DTOtherSTATE LICENSE NUMBER
KY1841253424OtherGROUP NPI