Provider Demographics
NPI:1225280423
Name:MENDENHALL, JESS ERIC (OD)
Entity Type:Individual
Prefix:DR
First Name:JESS
Middle Name:ERIC
Last Name:MENDENHALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E 1600 S
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-5204
Mailing Address - Country:US
Mailing Address - Phone:520-678-6567
Mailing Address - Fax:
Practice Address - Street 1:482 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-2410
Practice Address - Country:US
Practice Address - Phone:801-504-6448
Practice Address - Fax:801-504-6239
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7070612-9934152W00000X
UT7070612-8908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12457053OtherCAQH
UT1225280423Medicaid
12457053OtherCAQH
UTU000077822Medicare PIN