Healthcare Provider Details

I. General information

NPI: 1740972876
Provider Name (Legal Business Name): JESSICA CHUNG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LYONS ST
DEDHAM MA
02026-5599
US

IV. Provider business mailing address

1 LYONS ST
DEDHAM MA
02026-5599
US

V. Phone/Fax

Practice location:
  • Phone: 617-657-6455
  • Fax:
Mailing address:
  • Phone: 617-657-6455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5624
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: