Provider Demographics
NPI:1063642189
Name:GLORIA C JENNINGS OD, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GLORIA C JENNINGS OD, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-876-1112
Mailing Address - Street 1:1717 W 86TH ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2050
Mailing Address - Country:US
Mailing Address - Phone:317-876-1112
Mailing Address - Fax:317-876-2187
Practice Address - Street 1:1717 W 86TH ST
Practice Address - Street 2:SUITE 130
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2050
Practice Address - Country:US
Practice Address - Phone:317-876-1112
Practice Address - Fax:317-876-2187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100239200Medicaid