Provider Demographics
NPI:1346323540
Name:JENNIFER POOLE OD AND ASSOCIATES
Entity Type:Organization
Organization Name:JENNIFER POOLE OD AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:POOLE
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-942-9827
Mailing Address - Street 1:1270 ARBOR PLACE MALL
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7105
Mailing Address - Country:US
Mailing Address - Phone:770-942-9827
Mailing Address - Fax:770-577-2384
Practice Address - Street 1:2695 MARINER WAY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-8496
Practice Address - Country:US
Practice Address - Phone:770-942-9827
Practice Address - Fax:770-577-2384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1858152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA652052015AMedicaid
GA41ZCGFFMedicare Oscar/Certification
GAGRP7843Medicare PIN
GA652052015AMedicaid