Basic Information
| Provider Information | |||||||||
| NPI: | 1689609315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAEGER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 DABNEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524386132 | ||||||||
| FaxNumber: | 2524385161 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 DABNEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524386132 | ||||||||
| FaxNumber: | 2524385161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 01/11/2013 | ||||||||
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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 | 0913 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 8909439 | 05 | NC | MEDICAID | 8909407 | 05 | NC | MEDICAID | 890978E | 05 | NC | MEDICAID |