Provider Demographics
NPI:1225383268
Name:HEDLUND, JEZZARAE ROSE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEZZARAE
Middle Name:ROSE
Last Name:HEDLUND
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 1:521 W GARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-2954
Mailing Address - Country:US
Mailing Address - Phone:509-327-9505
Mailing Address - Fax:509-325-3277
Practice Address - Street 1:521 W GARLAND AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-2954
Practice Address - Country:US
Practice Address - Phone:509-327-9505
Practice Address - Fax:509-325-3277
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60297939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2044675Medicaid
WAG8925180OtherMEDICARE PTAN