Provider Demographics
NPI:1235127093
Name:JESKE, DOUGLAS N (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:N
Last Name:JESKE
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 1:6510 CAPITOL BLVD SE
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-5566
Mailing Address - Country:US
Mailing Address - Phone:360-352-6060
Mailing Address - Fax:
Practice Address - Street 1:6510 CAPITOL BLVD SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-5566
Practice Address - Country:US
Practice Address - Phone:360-352-6060
Practice Address - Fax:360-357-7339
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3087 TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG115000656Medicare PIN