Healthcare Provider Details

I. General information

NPI: 1710544564
Provider Name (Legal Business Name): JAMIE JOHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2368 CHERRY RD
ROCK HILL SC
29732-2165
US

IV. Provider business mailing address

753 PROSPECT LN
FORT MILL SC
29708-8164
US

V. Phone/Fax

Practice location:
  • Phone: 803-366-6111
  • Fax:
Mailing address:
  • Phone: 724-322-4733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2195
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number27OA00687600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: