Provider Demographics
NPI:1164738795
Name:PRUNTY, JENNIFER CAROL (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CAROL
Last Name:PRUNTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:CAROL
Other - Last Name:SINCLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4202 SW CORBETT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4259
Mailing Address - Country:US
Mailing Address - Phone:734-812-6186
Mailing Address - Fax:503-413-3113
Practice Address - Street 1:300 N GRAHAM ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1683
Practice Address - Country:US
Practice Address - Phone:503-413-3030
Practice Address - Fax:503-413-3113
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4547152W00000X
OR3436AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist