Provider Demographics
NPI:1730531336
Name:LEBURG-JETT, STEPHANIE (OD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LEBURG-JETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:LEBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 W GODFREY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3323
Mailing Address - Country:US
Mailing Address - Phone:215-276-6173
Mailing Address - Fax:
Practice Address - Street 1:1200 W GODFREY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3323
Practice Address - Country:US
Practice Address - Phone:215-276-6173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003157152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA13854027OtherCAQH NUMBER