Provider Demographics
NPI:1578529996
Name:KANE, JENNIFER M (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:KANE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:K
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1410 BLANDING ST
Mailing Address - Street 2:STE 200
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2967
Mailing Address - Country:US
Mailing Address - Phone:803-799-9919
Mailing Address - Fax:803-799-0788
Practice Address - Street 1:1333 TAYLOR ST
Practice Address - Street 2:SUITE 4G
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2923
Practice Address - Country:US
Practice Address - Phone:803-799-9919
Practice Address - Fax:803-799-0788
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD12895Medicaid
SCD12895Medicaid
SCU96279Medicare UPIN