Provider Demographics
NPI:1619158961
Name:SOWERS, JENNIFER LYNN (CERTIFIED OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:SOWERS
Suffix:
Gender:F
Credentials:CERTIFIED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 1/2 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:OGLESBY
Mailing Address - State:IL
Mailing Address - Zip Code:61348-1215
Mailing Address - Country:US
Mailing Address - Phone:815-883-9822
Mailing Address - Fax:815-883-9822
Practice Address - Street 1:105 1/2 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:OGLESBY
Practice Address - State:IL
Practice Address - Zip Code:61348-1215
Practice Address - Country:US
Practice Address - Phone:815-883-9822
Practice Address - Fax:815-883-9822
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL168711156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5664810001Medicare NSC