Provider Demographics
NPI:1215384532
Name:HUA, JENNIFER (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HUA
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 1:4605 BROCKTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0107
Mailing Address - Country:US
Mailing Address - Phone:951-686-4911
Mailing Address - Fax:
Practice Address - Street 1:4605 BROCKTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0107
Practice Address - Country:US
Practice Address - Phone:951-686-4911
Practice Address - Fax:951-686-9409
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33394-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT33394-TLGOtherCA STATE LICENSE