Healthcare Provider Details

I. General information

NPI: 1861284408
Provider Name (Legal Business Name): JESSI WIECK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 INSIGHT AVE
O FALLON IL
62269-2193
US

IV. Provider business mailing address

735 INSIGHT AVE
O FALLON IL
62269-2193
US

V. Phone/Fax

Practice location:
  • Phone: 618-628-2903
  • Fax:
Mailing address:
  • Phone: 618-628-2903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2025018913
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046012147
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number137510
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: