Provider Demographics
NPI:1801563994
Name:FLACK, JESSICA DAWN HISAKO (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN HISAKO
Last Name:FLACK
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 1:8400 BASS LAKE RD APT 111
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-5311
Mailing Address - Country:US
Mailing Address - Phone:403-630-5705
Mailing Address - Fax:
Practice Address - Street 1:6500 PENN AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1143
Practice Address - Country:US
Practice Address - Phone:612-798-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3716152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist