Provider Demographics
NPI:1184852303
Name:FERGUSON, JENNY BROOKE (OD)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:BROOKE
Last Name:FERGUSON
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:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:IA
Mailing Address - Zip Code:50028-0146
Mailing Address - Country:US
Mailing Address - Phone:515-270-6338
Mailing Address - Fax:515-270-6885
Practice Address - Street 1:11148 PLUM DR
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-6328
Practice Address - Country:US
Practice Address - Phone:515-270-6338
Practice Address - Fax:515-270-6885
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1636706OtherBCBS
IL8825444OtherMULTIPLAN
IL046010204Medicaid
IL0757500001Medicare NSC
IL210209Medicare UPIN
IL7235044OtherAETNA