Provider Demographics
NPI:1215933932
Name:KRIEG, JACOB J (OD)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:J
Last Name:KRIEG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:416 VALLEY VIEW DR
Mailing Address - Street 2:STE #100
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-2422
Mailing Address - Country:US
Mailing Address - Phone:308-635-1633
Mailing Address - Fax:308-635-2880
Practice Address - Street 1:416 VALLEY VIEW DR
Practice Address - Street 2:STE 100
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-1486
Practice Address - Country:US
Practice Address - Phone:308-635-1633
Practice Address - Fax:308-635-2880
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE876152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE507114125Medicaid
0219670001Medicare NSC
NE507114125Medicaid
CQ4076Medicare PIN