Provider Demographics
NPI:1063573400
Name:JESSEN, DIANE MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:JESSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:CURRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:1894 WENTZVILLE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3820
Practice Address - Country:US
Practice Address - Phone:636-377-2054
Practice Address - Fax:636-377-2056
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005019956152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063573400Medicaid
MOV07439Medicare UPIN
MOMA5227059Medicare UPIN
MO1063573400Medicaid