Healthcare Provider Details

I. General information

NPI: 1245887181
Provider Name (Legal Business Name): JESSICA MARIE BERRY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 LYME RD STE 201
HANOVER NH
03755-1260
US

IV. Provider business mailing address

29 BEECH ST APT B
NEWPORT NH
03773-1414
US

V. Phone/Fax

Practice location:
  • Phone: 603-643-2140
  • Fax:
Mailing address:
  • Phone: 978-766-3217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0995
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: