MEDICARE: JACQUELINE RITA DE JESSE OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OEGOO1547	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	442580095	OTHER	PA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	064195	OTHER	PA	HIGHMARK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	5704053	OTHER	PA	AETNA NON-HMO
5	0055699	OTHER	PA	AETNA HMO
6	0062198000	OTHER	PA	INDEPENDENCE BLUE CROSS

General Provider Information

NPI Number	:	1164419115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE RITA DE JESSE OD

Provider Business Mailing Address
First Line	:	4106 EDGMONT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-2314
Country	:	US
Telephone Number	:	610-872-8989
Fax Number	:	610-872-5220

Provider Business Practice Location Address
First Line	:	4106 EDGMONT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-2314
Country	:	US
Telephone Number	:	610-872-8989
Fax Number	:	610-872-5220

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	11/25/2008

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