Provider Demographics
NPI:1487747887
Name:EDWARDS, JACQUETTA (OD)
Entity type:Individual
Prefix:DR
First Name:JACQUETTA
Middle Name:
Last Name:EDWARDS
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 1:651 KAPKOWSKI RD
Mailing Address - Street 2:SUITE 1236
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-4901
Mailing Address - Country:US
Mailing Address - Phone:908-354-1077
Mailing Address - Fax:908-354-1344
Practice Address - Street 1:279 FERRY ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-3400
Practice Address - Country:US
Practice Address - Phone:973-344-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA004989152W00000X
NJ27OM00119300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ088387Medicare ID - Type Unspecified
NJU61966Medicare UPIN