Provider Demographics
NPI:1922395854
Name:JONES, JESSICA CARSON (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:CARSON
Last Name:JONES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:CARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:9111 KENNERLY ROAD
Mailing Address - Street 2:STE A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128
Mailing Address - Country:US
Mailing Address - Phone:314-842-2020
Mailing Address - Fax:
Practice Address - Street 1:9911 KENNERLY RD
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2700
Practice Address - Country:US
Practice Address - Phone:314-842-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2686152W00000X
MO2012013574152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1922395854Medicaid
MO067820034Medicare PIN
MO074730032Medicare PIN
MO991630011Medicare PIN