Provider Demographics
NPI:1598250755
Name:WAYNE, JENNA (OD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WAYNE
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 1:1013 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2181
Mailing Address - Country:US
Mailing Address - Phone:860-233-2020
Mailing Address - Fax:
Practice Address - Street 1:402 SAWDUST RD
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-2243
Practice Address - Country:US
Practice Address - Phone:281-363-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3206152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist