Healthcare Provider Details

I. General information

NPI: 1972853554
Provider Name (Legal Business Name): JONATHON HUDSON JIMMERSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 WESTERN AVE
BRIGHTON MA
02135-1007
US

IV. Provider business mailing address

495 WESTERN AVE
BRIGHTON MA
02135-1007
US

V. Phone/Fax

Practice location:
  • Phone: 617-783-0500
  • Fax: 617-783-0500
Mailing address:
  • Phone: 617-783-0500
  • Fax: 617-562-1398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4751
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: