Provider Demographics
NPI:1689785636
Name:LAYMAN, JEAN L (OD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:L
Last Name:LAYMAN
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 1:460 NORTHDALE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-3364
Mailing Address - Country:US
Mailing Address - Phone:763-208-5832
Mailing Address - Fax:
Practice Address - Street 1:4405 PHEASANT RIDGE DR NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4531
Practice Address - Country:US
Practice Address - Phone:763-784-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1943152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN477M7WAOtherBC/BS OF MN GRP #
MN2203265OtherMEDICA
MN2100738OtherMEDICA DISPENSING
MN477M8LAOtherBC/BS OF MN IND #