Basic Information
| Provider Information | |||||||||
| NPI: | 1669484622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEDLICKA | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | GERARD | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 DAKOTA PT | ||||||||
| Address2: | |||||||||
| City: | JORDAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553521441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524923135 | ||||||||
| FaxNumber: | 9524753680 | ||||||||
| Practice Location | |||||||||
| Address1: | 744 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474053603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128558436 | ||||||||
| FaxNumber: | 8128551683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 10/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2631 | MN | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 18003875 | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 638817500 | 05 | MN | MEDICAID | 201259190 | 05 | IN | MEDICAID |