Provider Demographics
NPI:1174193924
Name:WELLEN, JENNA LEE (OD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LEE
Last Name:WELLEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 W MICHIGAN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:317-278-1470
Mailing Address - Fax:
Practice Address - Street 1:1160 W MICHIGAN ST STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-278-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004278A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist