Provider Demographics
NPI:1407214737
Name:JENISCH VISION CARE PLLC
Entity Type:Organization
Organization Name:JENISCH VISION CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:IDAAYU
Authorized Official - Middle Name:R
Authorized Official - Last Name:JENISCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:253-350-1437
Mailing Address - Street 1:510 E MAIN STE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-5613
Mailing Address - Country:US
Mailing Address - Phone:253-840-4909
Mailing Address - Fax:253-840-4909
Practice Address - Street 1:5101 S 283RD PL
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-1927
Practice Address - Country:US
Practice Address - Phone:253-840-4909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60195908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty