Healthcare Provider Details

I. General information

NPI: 1922630136
Provider Name (Legal Business Name): JESSICA VICKERY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WESTHAMPTON STA
RICHMOND VA
23226-3330
US

IV. Provider business mailing address

400 WESTHAMPTON STA
RICHMOND VA
23226-3330
US

V. Phone/Fax

Practice location:
  • Phone: 804-287-4200
  • Fax: 804-282-4048
Mailing address:
  • Phone: 804-287-4200
  • Fax: 804-282-4048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTA2694
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003239
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: