Provider Demographics
NPI:1760121206
Name:WEISS, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:WEISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 WOODROW ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-1224
Mailing Address - Country:US
Mailing Address - Phone:215-290-9187
Mailing Address - Fax:
Practice Address - Street 1:1920 PICKENS ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2632
Practice Address - Country:US
Practice Address - Phone:803-779-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCOPT.2348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty