Healthcare Provider Details

I. General information

NPI: 1093880080
Provider Name (Legal Business Name): JESSICA MARY BEARER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA MARY WHITTEMORE OD

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12606 HOLLY RD
GRAND BLANC MI
48439
US

IV. Provider business mailing address

12606 HOLLY RD
GRAND BLANC MI
48439-2447
US

V. Phone/Fax

Practice location:
  • Phone: 810-694-3652
  • Fax: 810-694-0963
Mailing address:
  • Phone: 810-694-3652
  • Fax: 810-694-0963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004285
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: