Provider Demographics
NPI:1568815611
Name:BENJAMIN, JESSIKA (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSIKA
Middle Name:
Last Name:BENJAMIN
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 1:9337 MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1924
Mailing Address - Country:US
Mailing Address - Phone:909-624-6809
Mailing Address - Fax:909-624-7487
Practice Address - Street 1:471 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4219
Practice Address - Country:US
Practice Address - Phone:909-788-3433
Practice Address - Fax:909-624-7487
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33415TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist