Provider Demographics
NPI:1790985034
Name:LETOURNEAU, JACOB W (OD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:W
Last Name:LETOURNEAU
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 1:831 VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2665
Mailing Address - Country:US
Mailing Address - Phone:785-843-5665
Mailing Address - Fax:
Practice Address - Street 1:831 VERMONT ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2665
Practice Address - Country:US
Practice Address - Phone:785-843-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1779152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0000065102Medicare PIN