Provider Demographics
NPI:1093243487
Name:TYLER, JENNA KATHERINE (OD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:KATHERINE
Last Name:TYLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:KATHERINE
Other - Last Name:TYLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1876 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-1133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-1317
Practice Address - Country:US
Practice Address - Phone:740-385-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6585152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist