Provider Demographics
NPI:1518052083
Name:LESSLIE, JENNIFER MAIZE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MAIZE
Last Name:LESSLIE
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 1:824 HIGH BATTERY CIR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7881
Mailing Address - Country:US
Mailing Address - Phone:843-881-1292
Mailing Address - Fax:
Practice Address - Street 1:1370 REMOUNT ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-747-7663
Practice Address - Fax:843-747-7665
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1131152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD11315Medicaid
SCD11315Medicaid
SCU792387214Medicare ID - Type Unspecified