Provider Demographics
NPI:1508055732
Name:JERUSS, JEFFREY GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GLENN
Last Name:JERUSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 SEWELL MILL RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-2804
Mailing Address - Country:US
Mailing Address - Phone:770-578-1900
Mailing Address - Fax:770-578-6623
Practice Address - Street 1:2255 SEWELL MILL RD
Practice Address - Street 2:SUITE 310
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-2804
Practice Address - Country:US
Practice Address - Phone:770-578-1900
Practice Address - Fax:770-578-6623
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001332152W00000X, 152WC0802X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT-93916Medicare UPIN
GA41ZCCMHMedicare PIN