Healthcare Provider Details

I. General information

NPI: 1619383106
Provider Name (Legal Business Name): JESSICA SI-DIH LIU O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA S LEE

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 LILLY RD NE
OLYMPIA WA
98506-5196
US

IV. Provider business mailing address

700 LILLY RD NE
OLYMPIA WA
98506-5196
US

V. Phone/Fax

Practice location:
  • Phone: 360-923-7650
  • Fax:
Mailing address:
  • Phone: 360-923-7650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1807-741AT
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60465096
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: