Provider Demographics
NPI:1043376171
Name:WORRELL, JEFFREY B (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:B
Last Name:WORRELL
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4503
Mailing Address - Country:US
Mailing Address - Phone:360-336-9559
Mailing Address - Fax:360-336-9559
Practice Address - Street 1:1611 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4503
Practice Address - Country:US
Practice Address - Phone:360-336-9559
Practice Address - Fax:360-336-9559
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2021368Medicaid
WA2021368Medicaid