Provider Demographics
NPI:1316921810
Name:CAMERON, JESSICA M (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:CAMERON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-1526
Mailing Address - Country:US
Mailing Address - Phone:906-420-8322
Mailing Address - Fax:906-420-8315
Practice Address - Street 1:20 S 10TH ST
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-1526
Practice Address - Country:US
Practice Address - Phone:906-420-8322
Practice Address - Fax:906-420-8315
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4551382Medicaid
MI4551391Medicaid
MI4551373Medicaid
MIU97622Medicare UPIN
MI4551391Medicaid