Healthcare Provider Details

I. General information

NPI: 1710355490
Provider Name (Legal Business Name): JESSIE LALONDE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 11/01/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6705 E MCDOWELL RD
MESA AZ
85215-1751
US

IV. Provider business mailing address

4800 N 22ND ST STE 210
PHOENIX AZ
85016-4963
US

V. Phone/Fax

Practice location:
  • Phone: 480-985-7400
  • Fax: 480-396-6362
Mailing address:
  • Phone: 602-955-1000
  • Fax: 602-508-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002542
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004904
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: