Provider Demographics
NPI:1619998192
Name:HENLEY, JON MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MICHAEL
Last Name:HENLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:876 N MOUNTAIN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4166
Mailing Address - Country:US
Mailing Address - Phone:909-982-0900
Mailing Address - Fax:909-982-7657
Practice Address - Street 1:876 N MOUNTAIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4166
Practice Address - Country:US
Practice Address - Phone:909-982-0900
Practice Address - Fax:909-982-7657
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10246T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0102460Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAZZZ28614ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
CAU68637Medicare UPIN