Provider Demographics
NPI:1467604520
Name:VELASCO, JENNIFER (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:VELASCO
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 1:6024 RIDGE AVE
Mailing Address - Street 2:STE 116 - BOX 133
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-5229
Mailing Address - Country:US
Mailing Address - Phone:484-367-5112
Mailing Address - Fax:
Practice Address - Street 1:154 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-4103
Practice Address - Country:US
Practice Address - Phone:484-580-8873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002994152W00000X
VA0618001929152W00000X
TNT3144152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist