Provider Demographics
NPI:1508899923
Name:MALPASS, JENNIFER JOY (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOY
Last Name:MALPASS
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 1:19 N RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510
Mailing Address - Country:US
Mailing Address - Phone:630-879-9338
Mailing Address - Fax:630-879-9344
Practice Address - Street 1:19 N RANDALL RD
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510
Practice Address - Country:US
Practice Address - Phone:630-879-9338
Practice Address - Fax:630-879-9344
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46007265152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL325110Medicare ID - Type Unspecified
U41097Medicare UPIN