Provider Demographics
NPI:1780644948
Name:JACOBS, RENEE KATHLEEN (OD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:KATHLEEN
Last Name:JACOBS
Suffix:
Gender:F
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:PO BOX 150473
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-0473
Mailing Address - Country:US
Mailing Address - Phone:303-979-6910
Mailing Address - Fax:303-979-2212
Practice Address - Street 1:9862 W BELLEVIEW AVE
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-2101
Practice Address - Country:US
Practice Address - Phone:303-979-6910
Practice Address - Fax:303-979-2212
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08915423Medicaid
CO08915423Medicaid