Provider Demographics
NPI:1922019918
Name:JEZICK, JEANETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:
Last Name:JEZICK
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 1:1663 ROUTE 12
Mailing Address - Street 2:PO BOX 421
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-1500
Mailing Address - Country:US
Mailing Address - Phone:860-464-1040
Mailing Address - Fax:860-464-1044
Practice Address - Street 1:1663 ROUTE 12
Practice Address - Street 2:
Practice Address - City:GALES FERRY
Practice Address - State:CT
Practice Address - Zip Code:06335-1500
Practice Address - Country:US
Practice Address - Phone:860-464-1040
Practice Address - Fax:860-464-1044
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004132429Medicaid
CT004132429Medicaid
CTU46251Medicare UPIN