Provider Demographics
NPI:1962068379
Name:HARRISON, JEDIAH WILLIAM (OD)
Entity type:Individual
Prefix:
First Name:JEDIAH
Middle Name:WILLIAM
Last Name:HARRISON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 W STUART DR STE 7
Mailing Address - Street 2:
Mailing Address - City:HILLSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24343-1555
Mailing Address - Country:US
Mailing Address - Phone:276-728-9323
Mailing Address - Fax:276-728-0400
Practice Address - Street 1:843 W STUART DR STE 7
Practice Address - Street 2:
Practice Address - City:HILLSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24343-1555
Practice Address - Country:US
Practice Address - Phone:276-728-9323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0618002783152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1063704435OtherGROUP NPI
VA0618002783OtherLICENSE
VA1962068379OtherNATIONAL PROVIDER NUMBER