Provider Demographics
NPI:1356843999
Name:ISLAM, JESSICA CHASE (OD, MPH, FAAO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CHASE
Last Name:ISLAM
Suffix:
Gender:F
Credentials:OD, MPH, FAAO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:CHASE
Other - Last Name:BURTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6036 S WILSON DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-4969
Mailing Address - Country:US
Mailing Address - Phone:304-282-1753
Mailing Address - Fax:
Practice Address - Street 1:2000 N NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7808
Practice Address - Country:US
Practice Address - Phone:217-356-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ002555152W00000X
IL046011171152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist