Provider Demographics
NPI:1174684401
Name:REGALADO-ELLIS, JENNIFER ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:REGALADO-ELLIS
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 1:312 RIM ROCK DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-8261
Mailing Address - Country:US
Mailing Address - Phone:512-863-5314
Mailing Address - Fax:
Practice Address - Street 1:9600 S. IH 35 SVS. RD., SB #S-225
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748
Practice Address - Country:US
Practice Address - Phone:512-291-0876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5341TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist