Provider Demographics
NPI:1396848891
Name:STEPHEN S JENNINGS OD LLC
Entity Type:Organization
Organization Name:STEPHEN S JENNINGS OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER, PRESIDENT,& SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:SELPH
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:804-730-4171
Mailing Address - Street 1:9291 LAUREL GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2969
Mailing Address - Country:US
Mailing Address - Phone:804-730-4171
Mailing Address - Fax:804-730-0438
Practice Address - Street 1:9291 LAUREL GROVE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2969
Practice Address - Country:US
Practice Address - Phone:804-730-4171
Practice Address - Fax:804-730-0438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA194180OtherANTHEM
VA010300258Medicaid
VA5759880002Medicare NSC
VA010300258Medicaid
VAC09956Medicare PIN
VA580000720Medicare ID - Type UnspecifiedRAILROAD MEDIC. PAL. GBA
VA00X190S01Medicare PIN
VA194180OtherANTHEM