Provider Demographics
NPI:1578610465
Name:LUCY, JEANIE C (OD)
Entity Type:Individual
Prefix:DR
First Name:JEANIE
Middle Name:C
Last Name:LUCY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JEANIE
Other - Middle Name:C
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:555 31ST ST STE 306-P
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1235
Mailing Address - Country:US
Mailing Address - Phone:630-960-3928
Mailing Address - Fax:
Practice Address - Street 1:3450 LACEY RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515
Practice Address - Country:US
Practice Address - Phone:630-743-4500
Practice Address - Fax:630-743-4537
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008653Medicaid