Provider Demographics
NPI:1669951380
Name:CRABTREE, JESSIE (OD)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:CRABTREE
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 1:11280 LIMB BRANCH LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6035
Mailing Address - Country:US
Mailing Address - Phone:618-889-3822
Mailing Address - Fax:
Practice Address - Street 1:1508 SIOUX DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5200
Practice Address - Country:US
Practice Address - Phone:618-993-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist