Provider Demographics
NPI:1659054492
Name:STEPHENS, JESSICA MARIE (LDO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S TUTTLE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1556
Mailing Address - Country:US
Mailing Address - Phone:937-325-2816
Mailing Address - Fax:937-325-2818
Practice Address - Street 1:200 S TUTTLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1556
Practice Address - Country:US
Practice Address - Phone:937-325-2816
Practice Address - Fax:937-325-2818
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017608-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician