Provider Demographics
NPI:1639582109
Name:JOHNSON, JENNI (OD)
Entity Type:Individual
Prefix:
First Name:JENNI
Middle Name:
Last Name:JOHNSON
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 1:3750 VIRGINIA BEACH BLVD STE I
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-3411
Mailing Address - Country:US
Mailing Address - Phone:757-486-1712
Mailing Address - Fax:
Practice Address - Street 1:3750 VIRGINIA BEACH BLVD STE I
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-3411
Practice Address - Country:US
Practice Address - Phone:757-486-1712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2015-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002330152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist