Provider Demographics
NPI:1497314355
Name:WANG, JESSICA LAN (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAN
Last Name:WANG
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 1:2830 JACKSON AVE APT 48F
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3326
Mailing Address - Country:US
Mailing Address - Phone:469-230-0666
Mailing Address - Fax:
Practice Address - Street 1:2830 JACKSON AVE APT 48F
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3326
Practice Address - Country:US
Practice Address - Phone:469-230-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9768T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist