Basic Information
| Provider Information | |||||||||
| NPI: | 1063573400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESSEN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CURRY | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15933 CLAYTON RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630112172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6369382650 | ||||||||
| Practice Location | |||||||||
| Address1: | 1894 WENTZVILLE PKWY | ||||||||
| Address2: | |||||||||
| City: | WENTZVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633853820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363772054 | ||||||||
| FaxNumber: | 6363772056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 10/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2005019956 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1063573400 | 05 | MO | MEDICAID |