Provider Demographics
NPI:1780008508
Name:ARCHAMBAULT, JESSICA MERCADO (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MERCADO
Last Name:ARCHAMBAULT
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 1:12759 FOOTHILL BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12759 FOOTHILL BLVD STE D
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9336
Practice Address - Country:US
Practice Address - Phone:909-899-0026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14819152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist