Provider Demographics
NPI:1578902037
Name:ANDERSON, JENNIFER A (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:ANDERSON
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 1:316 WILLOW DELL LN
Mailing Address - Street 2:
Mailing Address - City:LEOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17540-1645
Mailing Address - Country:US
Mailing Address - Phone:215-806-5914
Mailing Address - Fax:
Practice Address - Street 1:2791 S QUEEN ST
Practice Address - Street 2:
Practice Address - City:DALLASTOWN
Practice Address - State:PA
Practice Address - Zip Code:17313-9540
Practice Address - Country:US
Practice Address - Phone:717-741-4788
Practice Address - Fax:717-741-5945
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002794152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist