Healthcare Provider Details

I. General information

NPI: 1316921810
Provider Name (Legal Business Name): JESSICA M CAMERON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 S 10TH ST
GLADSTONE MI
49837-1526
US

IV. Provider business mailing address

20 S 10TH ST
GLADSTONE MI
49837-1526
US

V. Phone/Fax

Practice location:
  • Phone: 906-420-8322
  • Fax: 906-420-8315
Mailing address:
  • Phone: 906-420-8322
  • Fax: 906-420-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004220
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: