Provider Demographics
NPI:1558373621
Name:STEPHEN S JENNINGS OD LLC
Entity Type:Organization
Organization Name:STEPHEN S JENNINGS OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MANGER, PRESIDENT, SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:SELPH
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:804-262-5142
Mailing Address - Street 1:2301 HILLIARD RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-4525
Mailing Address - Country:US
Mailing Address - Phone:804-262-5142
Mailing Address - Fax:804-262-6257
Practice Address - Street 1:2301 HILLIARD RD
Practice Address - Street 2:SUITE 3
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-4525
Practice Address - Country:US
Practice Address - Phone:804-262-5142
Practice Address - Fax:804-262-6257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA194180OtherANTHEM 2ND OFFICE
VA194188OtherANTHEM PRIMARY OFFICE
VA010300274Medicaid
VA010300258Medicaid
VA2146813OtherUNITED HEALTHCARE
VA271018OtherMAMSI,OPTIMUM CH.,ALLIAN
VA010300258Medicaid
VA5759880002Medicare NSC
VAC09956Medicare PIN
VA=========001OtherTRICARE
VA194180OtherANTHEM 2ND OFFICE
VAT21710Medicare UPIN
VADF6821Medicare ID - Type UnspecifiedRAILROAD,LLC GROUP
VA010300274Medicaid