Provider Demographics
NPI:1063467686
Name:FERRIS, JAN RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:RICHARD
Last Name:FERRIS
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 E GANSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1700
Mailing Address - Country:US
Mailing Address - Phone:517-789-6171
Mailing Address - Fax:517-789-6200
Practice Address - Street 1:900 E GANSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1700
Practice Address - Country:US
Practice Address - Phone:517-789-6171
Practice Address - Fax:517-789-6200
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI945036409Medicaid
MI0C86510Medicare ID - Type Unspecified
MI945036409Medicaid