Provider Demographics
NPI:1982451043
Name:OTTO, JESSICA JANE (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JANE
Last Name:OTTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JANE
Other - Last Name:BERNHARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8057 ELLA TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7026
Mailing Address - Country:US
Mailing Address - Phone:616-581-6189
Mailing Address - Fax:
Practice Address - Street 1:1700 S DRAKE RD STE D
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5721
Practice Address - Country:US
Practice Address - Phone:432-026-9888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005789152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist