Basic Information
| Provider Information | |||||||||
| NPI: | 1992157333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 184 MARKET DR | ||||||||
| Address2: | |||||||||
| City: | ATHOL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013319829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789393128 | ||||||||
| FaxNumber: | 9786502090 | ||||||||
| Practice Location | |||||||||
| Address1: | 93 EVERGREEN WAY | ||||||||
| Address2: | |||||||||
| City: | SOUTH WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060746975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606444362 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2016 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2993 | CT | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.