Provider Demographics
NPI:1760096150
Name:MOOBERRY, JACOB ANDREW (OD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ANDREW
Last Name:MOOBERRY
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 1:2115 W CHELTENHAM AVE APT A
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1030
Mailing Address - Country:US
Mailing Address - Phone:602-717-6089
Mailing Address - Fax:
Practice Address - Street 1:100 E STREET RD
Practice Address - Street 2:
Practice Address - City:WARMINSTER
Practice Address - State:PA
Practice Address - Zip Code:18974-3400
Practice Address - Country:US
Practice Address - Phone:215-293-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist