Provider Demographics
NPI:1518213420
Name:LEBER, JENNA NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:LEBER
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 1:3495 BAILEY AVE
Mailing Address - Street 2:EYE CLINIC - 6D
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:EYE CLINIC - 6D
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215
Practice Address - Country:US
Practice Address - Phone:631-261-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-29
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV-007838-1390200000X
NYTUV-007838152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program