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General NPI Number Information
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NPI Number | 1508055732
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Entity Type | Individual
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Provider Name | JEFFREY GLENN JERUSS O.D.
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Gender | Male
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Dates
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Enumeration Date | 10/24/2007
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Last Update Date | 11/21/2008
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Provider Practice Location Address
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Address Line | 2255 SEWELL MILL RD SUITE 310
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City | MARIETTA
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State | GA
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Zip | 30062-2804
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Country | US
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Telephone | 770-578-1900
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Fax | 770-578-6623
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Provider Business Mailing Address
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Address Line | 2255 SEWELL MILL RD SUITE 310
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City | MARIETTA
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State | GA
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Zip | 30062-2804
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Country | US
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Telephone | 770-578-1900
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Fax | 770-578-6623
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT001332
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | OPT001332
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | OPT001332
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License Number State | GA
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