Provider Demographics
NPI:1134671506
Name:JESTIN, TACY MARY (OD)
Entity Type:Individual
Prefix:
First Name:TACY
Middle Name:MARY
Last Name:JESTIN
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 1:4317 MITCHELL LN
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-2895
Mailing Address - Country:US
Mailing Address - Phone:214-762-7858
Mailing Address - Fax:
Practice Address - Street 1:2223 S BUCKNER BLVD
Practice Address - Street 2:#235
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-8646
Practice Address - Country:US
Practice Address - Phone:469-357-3678
Practice Address - Fax:214-388-7636
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-01
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9019TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist