Healthcare Provider Details

I. General information

NPI: 1982802112
Provider Name (Legal Business Name): JESSICA BROOKE TEGEN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA BROOKE HUDSON OD

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SE 5TH ST
MADRAS OR
97741-1627
US

IV. Provider business mailing address

211 SE 5TH ST
MADRAS OR
97741-1627
US

V. Phone/Fax

Practice location:
  • Phone: 541-475-2020
  • Fax: 541-923-3776
Mailing address:
  • Phone: 541-475-2020
  • Fax: 541-475-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3215AT
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: