Provider Demographics
NPI:1407857444
Name:KELL, JENNIFER TASCA (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:TASCA
Last Name:KELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:TASCA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4401 MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77204-2020
Mailing Address - Country:US
Mailing Address - Phone:713-743-2020
Mailing Address - Fax:713-743-0963
Practice Address - Street 1:4401 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77204-2020
Practice Address - Country:US
Practice Address - Phone:713-743-2020
Practice Address - Fax:713-743-0963
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2077152W00000X, 152WL0500X
TX7676T152W00000X
TX7676152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286359901Medicaid
CO23371846Medicaid
COU74539Medicare UPIN