Provider Demographics
NPI:1972165058
Name:JACOB, JUSTINA MARIE (OD)
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:MARIE
Last Name:JACOB
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 1:1225 W BAY DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2203
Mailing Address - Country:US
Mailing Address - Phone:727-581-8706
Mailing Address - Fax:
Practice Address - Street 1:11925 SHELDON RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3644
Practice Address - Country:US
Practice Address - Phone:727-581-8760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC005903152W00000X
FLOPC5903152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist