Provider Demographics
NPI:1336692623
Name:ANDERSON CONNELL, JENNIFER EUNICE (OD, MS, BS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:EUNICE
Last Name:ANDERSON CONNELL
Suffix:
Gender:F
Credentials:OD, MS, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-2407
Mailing Address - Country:US
Mailing Address - Phone:870-762-2297
Mailing Address - Fax:
Practice Address - Street 1:527 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-2407
Practice Address - Country:US
Practice Address - Phone:870-762-2297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003222152W00000X
AR2764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR221415722Medicaid