Provider Demographics
NPI:1164869566
Name:MCKINNON, JENNIFER (OD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:TENBRINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14555 HARR RD
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1982 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1736
Practice Address - Country:US
Practice Address - Phone:517-349-0784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004749152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist