Provider Demographics
NPI:1780145482
Name:WELLS, JEFFREY KYLE
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:KYLE
Last Name:WELLS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3641 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-9023
Mailing Address - Country:US
Mailing Address - Phone:662-587-7852
Mailing Address - Fax:
Practice Address - Street 1:10490 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6207
Practice Address - Country:US
Practice Address - Phone:904-292-2505
Practice Address - Fax:904-262-1113
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5694152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist