Provider Demographics
NPI:1396880415
Name:JEWETT, KELSEY H (OD)
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:H
Last Name:JEWETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4767 ROCKY RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-4005
Mailing Address - Country:US
Mailing Address - Phone:530-209-3315
Mailing Address - Fax:
Practice Address - Street 1:1722 MANGROVE AVE STE 30
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2300
Practice Address - Country:US
Practice Address - Phone:530-209-3315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2009-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5883T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0058830Medicare PIN
CAT10154Medicare UPIN