Provider Demographics
NPI:1588157291
Name:WILLINGHAM, JESSE MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:MICHAEL
Last Name:WILLINGHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 SUCCESS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-7851
Mailing Address - Country:US
Mailing Address - Phone:843-203-0200
Mailing Address - Fax:
Practice Address - Street 1:717 OLD TROLLEY RD STE 3
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5287
Practice Address - Country:US
Practice Address - Phone:843-873-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008748152W00000X
SCOPT.2201152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist