Provider Demographics
NPI:1508365941
Name:DELOGLOS, JESSICA (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DELOGLOS
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 1:18676 NW CEDAR FALLS LOOP
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-6083
Mailing Address - Country:US
Mailing Address - Phone:610-969-5552
Mailing Address - Fax:
Practice Address - Street 1:15901 SW JENKINS RD
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97006-5045
Practice Address - Country:US
Practice Address - Phone:503-644-7615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-11
Last Update Date:2018-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4336AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist