Basic Information
| Provider Information | |||||||||
| NPI: | 1780162446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JESSURUN | ||||||||
| FirstName: | DEBORAH | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
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| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1031 GRANDIFLORA DR | ||||||||
| Address2: | |||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284517453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103710540 | ||||||||
| FaxNumber: | 9103712463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2018 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2606 | NC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.