Provider Demographics
NPI:1063466431
Name:WAGNER- JESKE, JESSICA (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WAGNER- JESKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:600 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-3210
Mailing Address - Country:US
Mailing Address - Phone:989-684-8840
Mailing Address - Fax:989-684-2536
Practice Address - Street 1:600 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-3210
Practice Address - Country:US
Practice Address - Phone:989-684-8840
Practice Address - Fax:989-684-2536
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004356152W00000X
MIJW004356152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0B87610015Medicare ID - Type Unspecified