Healthcare Provider Details

I. General information

NPI: 1487549069
Provider Name (Legal Business Name): JASMINE QUINTANA AVILA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 07/12/2025
Certification Date: 07/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 WASHBURN ST
SCRANTON PA
18504-2429
US

IV. Provider business mailing address

213 S SUMNER AVE
SCRANTON PA
18504-2579
US

V. Phone/Fax

Practice location:
  • Phone: 570-343-2591
  • Fax:
Mailing address:
  • Phone: 570-468-6553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG004280
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: