Provider Demographics
NPI:1477124956
Name:SU, JESSIE MENG-JYE (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:MENG-JYE
Last Name:SU
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 1:1643 CLYDE ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-0945
Mailing Address - Country:US
Mailing Address - Phone:714-363-8828
Mailing Address - Fax:
Practice Address - Street 1:5030 HAMNER AVE
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:91752-1009
Practice Address - Country:US
Practice Address - Phone:951-361-9092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34941152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist