Provider Demographics
NPI:1710269618
Name:KENT, JAKE DAVID (OD)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:DAVID
Last Name:KENT
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 1:1815 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9454
Mailing Address - Country:US
Mailing Address - Phone:360-746-8890
Mailing Address - Fax:360-393-4004
Practice Address - Street 1:1815 MAIN ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9454
Practice Address - Country:US
Practice Address - Phone:360-746-8890
Practice Address - Fax:360-393-4004
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60555806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2049506Medicaid
WAG8945106Medicare PIN
WAG8945100Medicare PIN
WAG8945107Medicare PIN
WA6253220001Medicare NSC
WAG8945101Medicare PIN