Provider Demographics
NPI:1659342020
Name:NEELEY, JEAN A (OD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:A
Last Name:NEELEY
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 1:1220 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CALISTOGA
Mailing Address - State:CA
Mailing Address - Zip Code:94515-1450
Mailing Address - Country:US
Mailing Address - Phone:707-942-4674
Mailing Address - Fax:707-942-0745
Practice Address - Street 1:1220 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1450
Practice Address - Country:US
Practice Address - Phone:707-942-4674
Practice Address - Fax:707-942-0745
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9321T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0093210Medicaid
CA0348710001Medicare NSC
CASD0093210Medicare ID - Type Unspecified
CASD0093210Medicaid