Provider Demographics
NPI:1437483716
Name:JENISCH, IDAAYU RATIH (OD)
Entity Type:Individual
Prefix:MRS
First Name:IDAAYU
Middle Name:RATIH
Last Name:JENISCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:IDAAYU
Other - Middle Name:RATIH
Other - Last Name:JENISCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:5101 S 283RD PL
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-1927
Mailing Address - Country:US
Mailing Address - Phone:253-520-2100
Mailing Address - Fax:
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:253-520-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-19
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60195908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist