Provider Demographics
NPI:1396373379
Name:STOFFEL, JENNA RAE (OD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:RAE
Last Name:STOFFEL
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 1:6725 MIAMI AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45243-3158
Mailing Address - Country:US
Mailing Address - Phone:513-561-7076
Mailing Address - Fax:
Practice Address - Street 1:6725 MIAMI AVE STE 101
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45243-3158
Practice Address - Country:US
Practice Address - Phone:513-561-7076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD.OD.61062249152W00000X
OHOPT.007115152W00000X
WA61062249152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2190934Medicaid