Provider Demographics
NPI:1730556580
Name:DUFOUR, JACOB (OD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DUFOUR
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 1:900 S 52ND ST STE 102
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8640
Mailing Address - Country:US
Mailing Address - Phone:479-657-6006
Mailing Address - Fax:479-340-0285
Practice Address - Street 1:101 DAWN DR
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-9314
Practice Address - Country:US
Practice Address - Phone:479-795-1411
Practice Address - Fax:479-795-1412
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2754152WV0400X
AR2754152W00000X, 152WP0200X
WAOD 60559129152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics