Provider Demographics
NPI:1841681400
Name:JACOB FAMILY EYECARE, LLC
Entity type:Organization
Organization Name:JACOB FAMILY EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:859-824-1333
Mailing Address - Street 1:20 FERGUSON BLVD
Mailing Address - Street 2:
Mailing Address - City:DRY RIDGE
Mailing Address - State:KY
Mailing Address - Zip Code:41035-8635
Mailing Address - Country:US
Mailing Address - Phone:859-824-1333
Mailing Address - Fax:859-824-1300
Practice Address - Street 1:20 FERGUSON BLVD
Practice Address - Street 2:
Practice Address - City:DRY RIDGE
Practice Address - State:KY
Practice Address - Zip Code:41035-8635
Practice Address - Country:US
Practice Address - Phone:859-824-1333
Practice Address - Fax:859-824-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1452DT152W00000X
KY1458DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77001576Medicaid
KY77001535Medicaid