Provider Demographics
NPI:1356443261
Name:ELAM, JENNIFER (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:ELAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3560 PINE GROVE AVE
Mailing Address - Street 2:STE 366
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-1994
Mailing Address - Country:US
Mailing Address - Phone:502-759-1123
Mailing Address - Fax:
Practice Address - Street 1:3560 PINE GROVE AVE
Practice Address - Street 2:STE 366
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-1994
Practice Address - Country:US
Practice Address - Phone:502-759-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1607DT152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation