Provider Demographics
NPI:1578682290
Name:DAVIS, JENNIFER (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DAVIS
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 1:604 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:OH
Mailing Address - Zip Code:43056-1204
Mailing Address - Country:US
Mailing Address - Phone:740-522-8444
Mailing Address - Fax:740-522-6493
Practice Address - Street 1:604 S 30TH ST
Practice Address - Street 2:
Practice Address - City:HEATH
Practice Address - State:OH
Practice Address - Zip Code:43056-1204
Practice Address - Country:US
Practice Address - Phone:740-522-8444
Practice Address - Fax:740-522-6493
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5544-T2458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2632011Medicaid
OH4165923Medicare PIN
OH4165921Medicare PIN
OHV06008Medicare UPIN
OH2632011Medicaid