Provider Demographics
NPI:1013311851
Name:SIRIWARDANE, JESICA MALI (OD)
Entity Type:Individual
Prefix:DR
First Name:JESICA
Middle Name:MALI
Last Name:SIRIWARDANE
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 1:2720 COUNCIL TREE AVE STE 148
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-6309
Mailing Address - Country:US
Mailing Address - Phone:970-530-3097
Mailing Address - Fax:
Practice Address - Street 1:2720 COUNCIL TREE AVE STE 148
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-6309
Practice Address - Country:US
Practice Address - Phone:970-530-3097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003101152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist