Healthcare Provider Details

I. General information

NPI: 1790785285
Provider Name (Legal Business Name): JESSICA A SIMON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 06/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 KENT RD
STOW OH
44224-4537
US

IV. Provider business mailing address

518 WEST AVE
TALLMADGE OH
44278-2117
US

V. Phone/Fax

Practice location:
  • Phone: 330-688-8811
  • Fax: 330-296-3231
Mailing address:
  • Phone: 330-630-9699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5416
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: