Provider Demographics
NPI:1508095464
Name:SHABA, JENNIFER JANE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:JANE
Last Name:SHABA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:SHABA
Other - Last Name:YALLDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:5600 W MAPLE RD STE A120
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3782
Mailing Address - Country:US
Mailing Address - Phone:248-847-3372
Mailing Address - Fax:248-243-8963
Practice Address - Street 1:5600 W MAPLE RD STE A120
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3782
Practice Address - Country:US
Practice Address - Phone:248-847-3372
Practice Address - Fax:248-243-8963
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004524152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management