Provider Demographics
NPI:1205183183
Name:FABER, JENNIFER SUE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SUE
Last Name:FABER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WAGONER
Other - Suffix:
Other - Last Name Type:Other Name
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 1:2145 HENDERSONVILLE RD
Practice Address - Street 2:SUITE D
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-9723
Practice Address - Country:US
Practice Address - Phone:828-681-8000
Practice Address - Fax:828-681-0990
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2277152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1205183183Medicaid
1205183183Medicare NSC