1083843163 NPI number — DR. JENNIFER HERMETZ YORK O.D.

Table of content: DR. JENNIFER HERMETZ YORK O.D. (NPI 1083843163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083843163 NPI number — DR. JENNIFER HERMETZ YORK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YORK
Provider First Name:
JENNIFER
Provider Middle Name:
HERMETZ
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HERMETZ
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
ALISON
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083843163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 410
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39204-3425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-373-0714
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 NORTHLAKE AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39157-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-707-5255
Provider Business Practice Location Address Fax Number:
601-707-5255
Provider Enumeration Date:
07/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  811 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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