Individual
JACOB CONDITT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
3500 W PETERSON AVE STE 401, CHICAGO, IL 60659-3307
(773) 588-3090
Mailing address
2712 MCDOUGALD ST, NEWPORT, AR 72112-3014
(870) 664-6632
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046011525
IL
390200000X
Student in an Organized Health Care Education/Training Program
11785522-9934
UT
Other
Enumeration date
06/06/2020
Last updated
08/23/2021
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