Provider Demographics
NPI:1174836373
Name:EVANS, JADYN (OD)
Entity Type:Individual
Prefix:
First Name:JADYN
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JADYN
Other - Middle Name:
Other - Last Name:WILKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:24640 JEFFERSON AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-9030
Mailing Address - Country:US
Mailing Address - Phone:619-804-6374
Mailing Address - Fax:
Practice Address - Street 1:24400 JACKSON AVE STE. A
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-1987
Practice Address - Country:US
Practice Address - Phone:951-677-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGE3092OtherMEDICARE PTAN