Provider Demographics
NPI:1114213261
Name:BISGROVE MAHN, JESSICA (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BISGROVE MAHN
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 1:3390 E WOODVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-4754
Mailing Address - Country:US
Mailing Address - Phone:262-914-4424
Mailing Address - Fax:
Practice Address - Street 1:7001 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1407
Practice Address - Country:US
Practice Address - Phone:414-571-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3232-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist