Provider Demographics
NPI:1033647425
Name:CROFT, JENNIFER (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:CROFT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:EICHELMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:9979 WINGHAVEN BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3628
Mailing Address - Country:US
Mailing Address - Phone:636-695-8554
Mailing Address - Fax:
Practice Address - Street 1:3821 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63376-6416
Practice Address - Country:US
Practice Address - Phone:636-928-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019023362152W00000X
GAOPT003011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1033647425Medicaid
GAOPT003011OtherGA LICENSE
SCOPT1988OtherSC LICENSE
GA003191097AMedicaid