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:PSC 477 BOX 2
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96306-0001
Mailing Address - Country:US
Mailing Address - Phone:315-264-4696
Mailing Address - Fax:
Practice Address - Street 1:PSC 477 BOX 2
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96306-0001
Practice Address - Country:US
Practice Address - Phone:315-264-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2025-08-04
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