Provider Demographics
NPI:1235326943
Name:SHENK, JENNIFER M (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:SHENK
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 1:703 ROSANNE DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504
Mailing Address - Country:US
Mailing Address - Phone:252-527-8804
Mailing Address - Fax:
Practice Address - Street 1:703 ROSANNE DRIVE
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504
Practice Address - Country:US
Practice Address - Phone:252-527-8804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5922869Medicaid
NC5922869Medicaid
NCNCB991AMedicare PIN