Provider Demographics
NPI:1194754325
Name:VANCIL, JESSICA JON (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JON
Last Name:VANCIL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JON
Other - Last Name:SMOOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:165 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:BUCKSPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04416-4123
Mailing Address - Country:US
Mailing Address - Phone:207-469-3022
Mailing Address - Fax:207-469-7211
Practice Address - Street 1:165 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:BUCKSPORT
Practice Address - State:ME
Practice Address - Zip Code:04416-4123
Practice Address - Country:US
Practice Address - Phone:207-469-3022
Practice Address - Fax:207-469-7211
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT839152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME$$$$$$$$$Medicare PIN
U-84944Medicare UPIN
ME6164160001Medicare NSC