Provider Demographics
NPI:1952714073
Name:MAI, JESSICA LYNN (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:MAI
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 1:13111 ROBERTA PL
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-2143
Mailing Address - Country:US
Mailing Address - Phone:714-638-7740
Mailing Address - Fax:
Practice Address - Street 1:77 WAINWRIGHT DR
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3975
Practice Address - Country:US
Practice Address - Phone:509-525-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14905152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist