Provider Demographics
NPI:1215797287
Name:BAKER, JESSIE GRACE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:GRACE
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIMBERVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22853-9522
Mailing Address - Country:US
Mailing Address - Phone:540-896-0641
Mailing Address - Fax:540-896-0725
Practice Address - Street 1:375 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TIMBERVILLE
Practice Address - State:VA
Practice Address - Zip Code:22853-9522
Practice Address - Country:US
Practice Address - Phone:540-896-0641
Practice Address - Fax:540-896-0725
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101004552156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician