Provider Demographics
NPI:1699742684
Name:JETTON, HEATHER M (OD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:M
Last Name:JETTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:400 WESTHAMPTON STA
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3330
Mailing Address - Country:US
Mailing Address - Phone:804-287-4200
Mailing Address - Fax:804-287-4210
Practice Address - Street 1:400 WESTHAMPTON STA
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3330
Practice Address - Country:US
Practice Address - Phone:804-287-4200
Practice Address - Fax:804-287-4210
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0300000348152W00000X
MA4543152W00000X
VA0618002640152W00000X
UT8163077-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA36991OtherHEALTH NEW ENGLAND
MA454300OtherCONNECTICARE, INC.
MAAA46054OtherHARVARD PILGRIM HEALTHCAR
MAW16443OtherBLUE CROSS BLUE SHIELD OF
MA0704598Medicaid
MAAA46054OtherHARVARD PILGRIM HEALTHCAR
MAV02469Medicare UPIN