Provider Demographics
NPI:1962600775
Name:WANON, JACOB JACQUES (OD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JACQUES
Last Name:WANON
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 1:440 N ALVERNON WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1958
Mailing Address - Country:US
Mailing Address - Phone:520-327-6211
Mailing Address - Fax:
Practice Address - Street 1:440 N ALVERNON WAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1958
Practice Address - Country:US
Practice Address - Phone:520-327-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT13290T152W00000X
AZ2326152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist