Healthcare Provider Details

I. General information

NPI: 1740239615
Provider Name (Legal Business Name): JASON C. WITTERS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/07/2023
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 NOLENSVILLE RD STE 104
NOLENSVILLE TN
37135-6101
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 615-815-1632
  • Fax: 615-534-2178
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3662
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: