Provider Demographics
NPI:1659572071
Name:IVERSON, JAYLENE K (OD)
Entity Type:Individual
Prefix:DR
First Name:JAYLENE
Middle Name:K
Last Name:IVERSON
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 1:1015 S LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-2100
Mailing Address - Country:US
Mailing Address - Phone:906-786-5181
Mailing Address - Fax:906-786-7403
Practice Address - Street 1:1015 S LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-2100
Practice Address - Country:US
Practice Address - Phone:906-786-5181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004422152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICM1588OtherRAILROAD MEDICARE
MI1659572071Medicaid
MI1497792386OtherNPI GROUP
MI900B110420OtherBLUE CROSS BLUE SHIELD
MI0B16014Medicare PIN
MI0150880001Medicare PIN