Provider Demographics
NPI:1790350296
Name:HABERMAN, JAKE RYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:RYAN
Last Name:HABERMAN
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 1:1620 SUPERIOR ST STE 3
Mailing Address - Street 2:
Mailing Address - City:WEBSTER CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50595-2913
Mailing Address - Country:US
Mailing Address - Phone:515-832-2401
Mailing Address - Fax:
Practice Address - Street 1:1620 SUPERIOR ST STE 3
Practice Address - Street 2:
Practice Address - City:WEBSTER CITY
Practice Address - State:IA
Practice Address - Zip Code:50595-2913
Practice Address - Country:US
Practice Address - Phone:515-832-2401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA108407152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty