Provider Demographics
NPI:1437209913
Name:POWELL, JENNIFER MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:POWELL
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 1:3115 ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2652
Mailing Address - Country:US
Mailing Address - Phone:919-493-7456
Mailing Address - Fax:919-493-1718
Practice Address - Street 1:3115 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707
Practice Address - Country:US
Practice Address - Phone:919-493-7456
Practice Address - Fax:919-493-1718
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2043152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093V0OtherBCBS PIN
NC5905982Medicaid
NC2474423AMedicare PIN