Provider Demographics
NPI:1801940580
Name:EBBESEN, JAY ROSER (OD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:ROSER
Last Name:EBBESEN
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 1:121 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3207
Mailing Address - Country:US
Mailing Address - Phone:815-756-6388
Mailing Address - Fax:815-756-4861
Practice Address - Street 1:121 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3207
Practice Address - Country:US
Practice Address - Phone:815-756-6388
Practice Address - Fax:815-756-4861
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046-007326Medicaid
IL0648450001Medicare NSC
ILT38102Medicare UPIN
IL718830Medicare PIN