Provider Demographics
NPI:1841674967
Name:FORTIN, JESSICA (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FORTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:LEADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:161 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2103
Mailing Address - Country:US
Mailing Address - Phone:978-937-9700
Mailing Address - Fax:
Practice Address - Street 1:161 JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2103
Practice Address - Country:US
Practice Address - Phone:978-937-9700
Practice Address - Fax:978-221-6728
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-18
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5110152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist