Provider Demographics
NPI:1538411871
Name:JAGGI, STEPHEN MARK (OD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:JAGGI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 COLLEGE WAY
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43 SMITH RD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02841-1006
Practice Address - Country:US
Practice Address - Phone:401-841-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CO0003131152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program