Provider Demographics
NPI:1922077320
Name:GRACE, JESSICA JANE (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:JANE
Last Name:GRACE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:JANE
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:403 E STATESVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2675
Mailing Address - Country:US
Mailing Address - Phone:704-799-0420
Mailing Address - Fax:704-658-9906
Practice Address - Street 1:403 E STATESVILLE AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2675
Practice Address - Country:US
Practice Address - Phone:704-799-0420
Practice Address - Fax:704-658-9906
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2193152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U91407Medicare UPIN