Provider Demographics
NPI:1205148806
Name:CONDIE, JESSICA A (OD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:A
Last Name:CONDIE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4-L PLAZA STE 35
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-4501
Mailing Address - Country:US
Mailing Address - Phone:309-343-1179
Mailing Address - Fax:309-343-1179
Practice Address - Street 1:3241 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3878
Practice Address - Country:US
Practice Address - Phone:312-949-7211
Practice Address - Fax:312-949-7389
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010394152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010394Medicaid
IL046010394Medicaid