Basic Information
| Provider Information | |||||||||
| NPI: | 1609490531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONDITT | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2712 MCDOUGALD ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721123014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706646632 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3500 W PETERSON AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606593307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735883090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2020 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 11785522-9934 | UT | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 152W00000X | 046011525 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.