Provider Demographics
NPI:1346211687
Name:COLLINS, JENNETH MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNETH
Middle Name:MARIE
Last Name:COLLINS
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 1:111 PROGRESS DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-9094
Mailing Address - Country:US
Mailing Address - Phone:419-484-8181
Mailing Address - Fax:419-484-1033
Practice Address - Street 1:111 PROGRESS DR
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-9094
Practice Address - Country:US
Practice Address - Phone:419-484-8181
Practice Address - Fax:419-484-1033
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5239/T2143152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2318487Medicaid
OH2318487Medicaid
OHU88893Medicare UPIN