Provider Demographics
NPI:1285776575
Name:CONNOLLY, JESSICA J (OD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:J
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:12121 E BROADWAY AVE
Mailing Address - Street 2:BLDG 1
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4972
Mailing Address - Country:US
Mailing Address - Phone:509-928-1212
Mailing Address - Fax:509-924-5035
Practice Address - Street 1:12121 E BROADWAY AVE STE 1
Practice Address - Street 2:BLDG 1
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4972
Practice Address - Country:US
Practice Address - Phone:509-928-1212
Practice Address - Fax:509-924-5035
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR3186T152W00000X
WA4120152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2006125Medicaid
WAG8916208Medicare PIN