Provider Demographics
NPI:1942512140
Name:DURHAM, JESSICA ELLIS (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ELLIS
Last Name:DURHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:HOLMAN
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4301 HILLSBORO PIKE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-3345
Mailing Address - Country:US
Mailing Address - Phone:615-297-7547
Mailing Address - Fax:615-297-7576
Practice Address - Street 1:4301 HILLSBORO PIKE
Practice Address - Street 2:SUITE 330
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-3345
Practice Address - Country:US
Practice Address - Phone:615-297-7547
Practice Address - Fax:615-297-7576
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1031413860Medicare UPIN