Provider Demographics
NPI:1992741441
Name:JANECEK, JACOB THOMAS (OD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:JANECEK
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 1:17430 NW SOLANO LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-2239
Mailing Address - Country:US
Mailing Address - Phone:503-533-8441
Mailing Address - Fax:503-533-8403
Practice Address - Street 1:1865 NW 169TH PL
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7310
Practice Address - Country:US
Practice Address - Phone:503-533-8441
Practice Address - Fax:503-533-8403
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2877AT152WV0400X, 152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181435Medicaid
OR181435Medicaid
ORU91182Medicare UPIN