Provider Demographics
NPI:1164803896
Name:TAI, JENNIFER (OD)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:TAI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:3140 CITRUS TOWER BLVD STE B
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6888
Practice Address - Country:US
Practice Address - Phone:352-243-2121
Practice Address - Fax:352-243-2140
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8769TG152W00000X
FLOPC5475152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist