Provider Demographics
NPI:1205277498
Name:STACY, JESSICA H (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:H
Last Name:STACY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:H
Other - Last Name:HILDEBRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3231 EGGLESTON FALLS RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148-4603
Mailing Address - Country:US
Mailing Address - Phone:901-395-3530
Mailing Address - Fax:
Practice Address - Street 1:9440 IRON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6601
Practice Address - Country:US
Practice Address - Phone:804-748-4877
Practice Address - Fax:804-796-9168
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002267152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVB227AMedicare PIN