Healthcare Provider Details

I. General information

NPI: 1962068379
Provider Name (Legal Business Name): JEDIAH WILLIAM HARRISON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 W STUART DR STE 7
HILLSVILLE VA
24343-1555
US

IV. Provider business mailing address

843 W STUART DR STE 7
HILLSVILLE VA
24343-1555
US

V. Phone/Fax

Practice location:
  • Phone: 276-728-9323
  • Fax:
Mailing address:
  • Phone: 276-728-9323
  • Fax: 276-728-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002783
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: