Provider Demographics
NPI:1528184447
Name:MANCINI, JENISE (OD)
Entity Type:Individual
Prefix:
First Name:JENISE
Middle Name:
Last Name:MANCINI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENISE
Other - Middle Name:KOZIOL
Other - Last Name:MANCINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:45 DOC STONE RD
Mailing Address - Street 2:101
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-4555
Mailing Address - Country:US
Mailing Address - Phone:540-720-2020
Mailing Address - Fax:540-288-2020
Practice Address - Street 1:45 DOC STONE RD
Practice Address - Street 2:101
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-4555
Practice Address - Country:US
Practice Address - Phone:540-720-2020
Practice Address - Fax:540-288-2020
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU19735Medicare UPIN