Provider Demographics
NPI:1023249513
Name:REESE, JACOB T (ABOC NCLEC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:T
Last Name:REESE
Suffix:
Gender:M
Credentials:ABOC NCLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3601
Mailing Address - Country:US
Mailing Address - Phone:316-440-1600
Mailing Address - Fax:316-267-9034
Practice Address - Street 1:610 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3601
Practice Address - Country:US
Practice Address - Phone:316-440-1600
Practice Address - Fax:316-267-9034
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician