Provider Demographics
NPI:1790489300
Name:JAY, JIM
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:JAY
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 1:3883 BURBANK RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-7220
Mailing Address - Country:US
Mailing Address - Phone:330-345-8641
Mailing Address - Fax:
Practice Address - Street 1:3883 BURBANK RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-7220
Practice Address - Country:US
Practice Address - Phone:330-345-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician