Provider Demographics
NPI:1568037059
Name:PENN, JEREMY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:LEE
Last Name:PENN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:308 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-1210
Practice Address - Country:US
Practice Address - Phone:859-234-1424
Practice Address - Fax:859-234-5463
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-11-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY2225DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist