Provider Demographics
NPI:1841338910
Name:DUSTIN, JESSICA R (ABOC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:DUSTIN
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 COUNTY HIGHWAY 128
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-3823
Mailing Address - Country:US
Mailing Address - Phone:518-762-2020
Mailing Address - Fax:
Practice Address - Street 1:135 COUNTY HIGHWAY 128
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-3823
Practice Address - Country:US
Practice Address - Phone:518-762-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5539351156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02772498Medicaid