Provider Demographics
NPI:1043605728
Name:JUEN, JESSICA MOTTA (LDO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MOTTA
Last Name:JUEN
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 HARBOR TOWN SQ STE 201
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-8890
Mailing Address - Country:US
Mailing Address - Phone:901-591-0372
Mailing Address - Fax:
Practice Address - Street 1:113 HARBOR TOWN SQ STE 201
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-8890
Practice Address - Country:US
Practice Address - Phone:901-591-0372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2514156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician