Healthcare Provider Details

I. General information

NPI: 1023572823
Provider Name (Legal Business Name): JEA OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 CLINTON PKWY
CLINTON MS
39056-4730
US

IV. Provider business mailing address

1200 N STATE ST STE 330
JACKSON MS
39202-2027
US

V. Phone/Fax

Practice location:
  • Phone: 601-924-9750
  • Fax: 601-925-9791
Mailing address:
  • Phone: 601-352-0274
  • Fax: 601-714-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: ROBERT AMORY MALLETTE
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 601-353-2020