Provider Demographics
NPI:1265474530
Name:JERVIS, KIRSTEN A (OD)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:A
Last Name:JERVIS
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 1:10 TRIEBLE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-7054
Mailing Address - Country:US
Mailing Address - Phone:570-836-2020
Mailing Address - Fax:570-836-5501
Practice Address - Street 1:10 TRIEBLE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-7054
Practice Address - Country:US
Practice Address - Phone:570-836-2020
Practice Address - Fax:570-836-5501
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000126152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0617860003Medicare NSC
U93821Medicare UPIN
PA066549Medicare ID - Type Unspecified