Provider Demographics
NPI:1467713594
Name:DAVIS, JESSICA MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MICHELLE
Other - Last Name:FOREMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:10660 S COUNTY ROAD 800 W
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47334-9713
Mailing Address - Country:US
Mailing Address - Phone:765-748-5219
Mailing Address - Fax:
Practice Address - Street 1:5535 S SCATTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-3140
Practice Address - Country:US
Practice Address - Phone:765-642-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003724A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201077970Medicaid
IN894060008Medicare PIN
INM400072536Medicare PIN
IN411610003Medicare PIN