Provider Demographics
NPI:1669484622
Name:JEDLICKA, JASON GERARD (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:GERARD
Last Name:JEDLICKA
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 1:830 DAKOTA PT
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-1441
Mailing Address - Country:US
Mailing Address - Phone:952-492-3135
Mailing Address - Fax:952-475-3680
Practice Address - Street 1:744 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3603
Practice Address - Country:US
Practice Address - Phone:812-855-8436
Practice Address - Fax:812-855-1683
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2631152W00000X
IN18003875152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN638817500Medicaid
IN201259190Medicaid
MN638817500Medicaid
IN544150015Medicare PIN
IN201259190Medicaid