Provider Demographics
NPI:1962764076
Name:QUESENBERRY, JARED PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:PAUL
Last Name:QUESENBERRY
Suffix:
Gender:M
Credentials:OD
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Other - Credentials:
Mailing Address - Street 1:1332 LOWRY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEDFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24523
Mailing Address - Country:US
Mailing Address - Phone:540-586-9575
Mailing Address - Fax:540-586-0129
Practice Address - Street 1:1332 LOWRY ST
Practice Address - Street 2:SUITE A
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523
Practice Address - Country:US
Practice Address - Phone:540-586-9575
Practice Address - Fax:540-586-0129
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0618002125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA145291Medicaid