Provider Demographics
NPI:1164419115
Name:DE JESSE, JACQUELINE RITA (OD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RITA
Last Name:DE JESSE
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 1:4106 EDGMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-2314
Mailing Address - Country:US
Mailing Address - Phone:610-872-8989
Mailing Address - Fax:610-872-5220
Practice Address - Street 1:4106 EDGMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-2314
Practice Address - Country:US
Practice Address - Phone:610-872-8989
Practice Address - Fax:610-872-5220
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEGOO1547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA064195OtherHIGHMARK
PA442580095OtherRAILROAD MEDICARE
PA0005487270005Medicaid
PA5704053OtherAETNA NON-HMO
PA0055699OtherAETNA HMO
PA0062198000OtherINDEPENDENCE BLUE CROSS
PA0264770001Medicare NSC
PA064195OtherHIGHMARK
PA0005487270005Medicaid