Provider Demographics
NPI:1619383106
Name:LIU, JESSICA SI-DIH (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SI-DIH
Last Name:LIU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:S
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5196
Mailing Address - Country:US
Mailing Address - Phone:360-923-7650
Mailing Address - Fax:
Practice Address - Street 1:700 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5196
Practice Address - Country:US
Practice Address - Phone:360-923-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1807-741AT152W00000X
WAOD60465096152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist