Provider Demographics
NPI:1710976311
Name:SCHOENENBERGER, JACOB L (OD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:L
Last Name:SCHOENENBERGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:L
Other - Last Name:SCHOENENBERGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:114 SOUTH MADISON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1320
Mailing Address - Country:US
Mailing Address - Phone:608-882-4990
Mailing Address - Fax:608-882-3980
Practice Address - Street 1:114 SOUTH MADISON ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1320
Practice Address - Country:US
Practice Address - Phone:608-882-4990
Practice Address - Fax:608-882-3980
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2327152W00000X
WI2327035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38578400Medicaid
WIT 83424Medicare UPIN
WI47336Medicare PIN
WI38578400Medicaid