Basic Information
| Provider Information | |||||||||
| NPI: | 1710355490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LALONDE | ||||||||
| FirstName: | JESSIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 N 22ND ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029551000 | ||||||||
| FaxNumber: | 6025084830 | ||||||||
| Practice Location | |||||||||
| Address1: | 6705 E MCDOWELL RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852151751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809857400 | ||||||||
| FaxNumber: | 4803966362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2015 | ||||||||
| LastUpdateDate: | 11/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT-002542 | AZ | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 4901004904 | MI | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 101209 | 05 | AZ | MEDICAID |