Provider Demographics
NPI:1942534235
Name:JANGULA, JESSE JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:JAMES
Last Name:JANGULA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 W 4TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-4978
Mailing Address - Country:US
Mailing Address - Phone:208-773-7434
Mailing Address - Fax:208-777-0836
Practice Address - Street 1:185 W 4TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-4978
Practice Address - Country:US
Practice Address - Phone:208-773-7434
Practice Address - Fax:208-777-0836
Is Sole Proprietor?:No
Enumeration Date:2009-09-20
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60099363152W00000X
IDODP-100218152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1942534235Medicaid
ID1942534235Medicaid