Provider Demographics
NPI:1396057089
Name:QUICK, JERICHO LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:JERICHO
Middle Name:LYNN
Last Name:QUICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:121 E NIBLACK RD
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-5401
Mailing Address - Country:US
Mailing Address - Phone:812-255-0559
Mailing Address - Fax:
Practice Address - Street 1:1813 WILLOW ST STE 2A
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591
Practice Address - Country:US
Practice Address - Phone:812-255-0559
Practice Address - Fax:812-316-0020
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003650A152WX0102X, 152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201008910AMedicaid
IN201008910AMedicaid