Provider Demographics
NPI:1972667889
Name:CHANG, JESSICA T (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:T
Last Name:CHANG
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 1:11414 MISSOURI AVE
Mailing Address - Street 2:UNIT D
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5578
Mailing Address - Country:US
Mailing Address - Phone:909-331-8888
Mailing Address - Fax:
Practice Address - Street 1:3525 W CARSON ST
Practice Address - Street 2:DEL AMO FASHION CENTER UNIT 30
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5704
Practice Address - Country:US
Practice Address - Phone:310-370-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12791152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist