Provider Demographics
NPI:1699437129
Name:DEWEESE, JACOB DANIEL (OD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DANIEL
Last Name:DEWEESE
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 1:3699 LENOX RD NE APT G47
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3489
Mailing Address - Country:US
Mailing Address - Phone:317-607-8930
Mailing Address - Fax:
Practice Address - Street 1:2200 ROSWELL RD STE 160
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-2984
Practice Address - Country:US
Practice Address - Phone:770-565-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist