Provider Demographics
NPI:1811760747
Name:DAVIS, JACOB BURLEY (OD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:BURLEY
Last Name:DAVIS
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 1:950 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-1489
Mailing Address - Country:US
Mailing Address - Phone:724-745-2020
Mailing Address - Fax:
Practice Address - Street 1:950 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CANONSBURG
Practice Address - State:PA
Practice Address - Zip Code:15317-1489
Practice Address - Country:US
Practice Address - Phone:724-745-2020
Practice Address - Fax:724-745-4888
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007229152W00000X
PAOEG004091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist