Provider Demographics
NPI:1073243630
Name:BOYCOTT, JESSIE (OD)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:BOYCOTT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3320 EXECUTIVE DR STE 111
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7445
Practice Address - Country:US
Practice Address - Phone:919-876-2427
Practice Address - Fax:919-850-9234
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3796152W00000X
NC2691152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometrist