Provider Demographics
NPI:1558744409
Name:WILLARD, JENNA MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MICHELLE
Last Name:WILLARD
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 VILLAGE SQ
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-2712
Mailing Address - Country:US
Mailing Address - Phone:978-256-5600
Mailing Address - Fax:978-703-0250
Practice Address - Street 1:19 VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-2712
Practice Address - Country:US
Practice Address - Phone:978-256-5600
Practice Address - Fax:978-703-0250
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5166152W00000X
PAOEG003049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110116574AMedicaid
S400330561Medicare PIN