Healthcare Provider Details

I. General information

NPI: 1205277498
Provider Name (Legal Business Name): JESSICA H STACY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA H HILDEBRAND

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 IRON BRIDGE RD
CHESTERFIELD VA
23832-6601
US

IV. Provider business mailing address

3231 EGGLESTON FALLS RD
RIDGEWAY VA
24148-4603
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-4877
  • Fax: 804-796-9168
Mailing address:
  • Phone: 901-395-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002267
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: