Provider Demographics
NPI:1366704611
Name:HARTMAN, JENESSA LEIGH (OD)
Entity type:Individual
Prefix:DR
First Name:JENESSA
Middle Name:LEIGH
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CHERRY HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3586
Mailing Address - Country:US
Mailing Address - Phone:541-296-1101
Mailing Address - Fax:
Practice Address - Street 1:301 CHERRY HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058
Practice Address - Country:US
Practice Address - Phone:541-296-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3592ATI152W00000X
MO2014027649152W00000X
WAOD60639931152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400076648Medicare UPIN