Provider Demographics
NPI:1205211349
Name:PRICE, JESSICA (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PRICE
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 1:11261 NALL AVE
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1669
Mailing Address - Country:US
Mailing Address - Phone:913-261-2020
Mailing Address - Fax:
Practice Address - Street 1:11261 NALL AVE
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1669
Practice Address - Country:US
Practice Address - Phone:913-261-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2013152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4050A0011Medicare PIN
KS405E00017Medicare PIN