Provider Demographics
NPI:1275682015
Name:SMALLEY-HUBER, JENNIFER LYNN (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:SMALLEY-HUBER
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 1:3353 MORAN RD
Mailing Address - Street 2:
Mailing Address - City:BIRCH RUN
Mailing Address - State:MI
Mailing Address - Zip Code:48415-9092
Mailing Address - Country:US
Mailing Address - Phone:989-777-1766
Mailing Address - Fax:
Practice Address - Street 1:3377 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3007
Practice Address - Country:US
Practice Address - Phone:810-733-3061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU87782Medicare UPIN
MIN34040010Medicare ID - Type Unspecified