Provider Demographics
NPI:1811759988
Name:NEW, JACOB ETHAN
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ETHAN
Last Name:NEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 RANDON TER FL 32746
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2636
Mailing Address - Country:US
Mailing Address - Phone:321-626-8947
Mailing Address - Fax:
Practice Address - Street 1:4108 PARK RD STE 205
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2260
Practice Address - Country:US
Practice Address - Phone:704-248-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist