Provider Demographics
NPI:1639148588
Name:WHIPPLE, JESSE DEON (OD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:DEON
Last Name:WHIPPLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 S GILBERT RD
Mailing Address - Street 2:#3
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6077
Mailing Address - Country:US
Mailing Address - Phone:480-545-8985
Mailing Address - Fax:480-545-9384
Practice Address - Street 1:1356 S GILBERT RD
Practice Address - Street 2:#3
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204
Practice Address - Country:US
Practice Address - Phone:480-545-8985
Practice Address - Fax:480-545-9384
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ$$$$$$$$$Medicare PIN
AZT76927Medicare UPIN
AZ0304460001Medicare NSC