Provider Demographics
NPI:1982802112
Name:TEGEN, JESSICA BROOKE (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BROOKE
Last Name:TEGEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:BROOKE
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:211 SE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-1627
Mailing Address - Country:US
Mailing Address - Phone:541-475-2020
Mailing Address - Fax:541-475-6118
Practice Address - Street 1:211 SE 5TH ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1627
Practice Address - Country:US
Practice Address - Phone:541-475-2020
Practice Address - Fax:541-923-3776
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3215AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3215ATIOtherSTATE LICENSE
OR244121Medicaid
ORR139478Medicare PIN
OR5770620001Medicare NSC