Provider Demographics
NPI:1255847802
Name:JETT, EDWARD RENEA (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:RENEA
Last Name:JETT
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6265 BROCKPORT SPENCERPORT RD
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2605
Mailing Address - Country:US
Mailing Address - Phone:585-395-0456
Mailing Address - Fax:585-395-1195
Practice Address - Street 1:6265 BROCKPORT SPENCERPORT RD
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420
Practice Address - Country:US
Practice Address - Phone:585-395-0456
Practice Address - Fax:585-395-1195
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007668-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician