Provider Demographics
NPI:1790309250
Name:WOLFE, JESSICA (OD, MS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:WOLFE
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S TIPPECANOE DR
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1194
Mailing Address - Country:US
Mailing Address - Phone:937-667-1270
Mailing Address - Fax:
Practice Address - Street 1:115 S TIPPECANOE DR
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-1194
Practice Address - Country:US
Practice Address - Phone:937-667-1270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6866152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6866OtherSTATE LICENSE