Provider Demographics
NPI:1285682245
Name:DENHARTOG, JENNIFER (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:DENHARTOG
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 1:4702 148TH ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50323-2074
Mailing Address - Country:US
Mailing Address - Phone:515-210-9900
Mailing Address - Fax:
Practice Address - Street 1:12695 UNIVERSITY AVE STE 170
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8217
Practice Address - Country:US
Practice Address - Phone:515-512-1444
Practice Address - Fax:515-512-1440
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2018-10-03
Deactivation Date:2018-09-11
Deactivation Code:
Reactivation Date:2018-09-17
Provider Licenses
StateLicense IDTaxonomies
IA02164152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA24569OtherBC/BS INDIVIDUAL NUMBER
IA0229344Medicaid
IA0893990001OtherDMERC
IA24569OtherBC/BS INDIVIDUAL NUMBER
IA0229344Medicaid
IA0893990001OtherDMERC
IA24569OtherBC/BS INDIVIDUAL NUMBER