Provider Demographics
NPI:1972640977
Name:JACOB, JAMES LELAND (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LELAND
Last Name:JACOB
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 1:181 SOUTHERN OAKS CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4068
Mailing Address - Country:US
Mailing Address - Phone:636-949-5004
Mailing Address - Fax:
Practice Address - Street 1:6664 MEXICO RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-4131
Practice Address - Country:US
Practice Address - Phone:636-970-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2230152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist