Provider Demographics
NPI:1164290516
Name:VITALE, JESSICA A (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:VITALE
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 1:1600 W LAKE ST STE 106
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-1822
Mailing Address - Country:US
Mailing Address - Phone:630-773-9410
Mailing Address - Fax:630-773-9473
Practice Address - Street 1:1600 W LAKE ST STE 106
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-1822
Practice Address - Country:US
Practice Address - Phone:630-773-9410
Practice Address - Fax:630-773-9473
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-011816152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist