Provider Demographics
NPI:1801840657
Name:JACOBS, KEVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:JACOBS
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 1:1905 ABBOT RD STE 1
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8571
Mailing Address - Country:US
Mailing Address - Phone:517-580-8733
Mailing Address - Fax:517-337-1854
Practice Address - Street 1:1905 ABBOT RD STE 1
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8571
Practice Address - Country:US
Practice Address - Phone:517-580-8733
Practice Address - Fax:517-337-1854
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004013152WC0802X, 152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI22-70122OtherPHP-MEDICAID
MI86-4792288Medicaid
MI22-00122OtherPHYSICANS HEALTH PLAN-PHP
MI900C313100OtherBCBS
MI1019456OtherMCLAREN
MI94-4318770Medicaid
U79156Medicare UPIN
MI900C313100OtherBCBS
MI22-70122OtherPHP-MEDICAID
MIP16060001Medicare ID - Type UnspecifiedPROVIDER #