Provider Demographics
NPI:1699223974
Name:MARK, JESSICA (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:FORDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13904 N DALE MABRY HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2446
Mailing Address - Country:US
Mailing Address - Phone:813-908-2020
Mailing Address - Fax:813-908-2133
Practice Address - Street 1:4211 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1917
Practice Address - Country:US
Practice Address - Phone:863-658-3003
Practice Address - Fax:863-385-1233
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5280152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018930100Medicaid