Provider Demographics
NPI:1154552875
Name:CLEMENTS, JEFFREY (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-1837
Mailing Address - Country:US
Mailing Address - Phone:608-825-2020
Mailing Address - Fax:
Practice Address - Street 1:1455 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1837
Practice Address - Country:US
Practice Address - Phone:608-825-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3163-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist