Provider Demographics
NPI:1124865662
Name:AUSTIN, JESSE COLLIN (LDO)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:COLLIN
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 NEW BRITAIN AVE APT N2
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2035
Mailing Address - Country:US
Mailing Address - Phone:203-578-0294
Mailing Address - Fax:
Practice Address - Street 1:126 NEW BRITAIN AVE APT N2
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-2035
Practice Address - Country:US
Practice Address - Phone:203-578-0294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1913156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician