Provider Demographics
NPI:1134117633
Name:YANG, JESSICA (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:YANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12150 ANNAPOLIS RD
Mailing Address - Street 2:STE 111
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9183
Mailing Address - Country:US
Mailing Address - Phone:301-779-0844
Mailing Address - Fax:
Practice Address - Street 1:2321 FOREST DR STE E
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-4679
Practice Address - Country:US
Practice Address - Phone:410-266-3369
Practice Address - Fax:410-266-9448
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV-6853152W00000X
MDTA2079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV04439Medicare UPIN
NYC380E1Medicare ID - Type Unspecified