Provider Demographics
NPI:1023572823
Name:JEA OPTICAL LLC
Entity Type:Organization
Organization Name:JEA OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:AMORY
Authorized Official - Last Name:MALLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-353-2020
Mailing Address - Street 1:1200 N STATE ST STE 330
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2027
Mailing Address - Country:US
Mailing Address - Phone:601-352-0274
Mailing Address - Fax:601-714-5110
Practice Address - Street 1:102 CLINTON PKWY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4730
Practice Address - Country:US
Practice Address - Phone:601-924-9750
Practice Address - Fax:601-925-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies