Provider Demographics
NPI:1821352832
Name:JENNINGS, EMILIE JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:EMILIE
Middle Name:JEAN
Last Name:JENNINGS
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 1:1900 CHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1213
Mailing Address - Country:US
Mailing Address - Phone:765-962-2020
Mailing Address - Fax:
Practice Address - Street 1:1900 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1213
Practice Address - Country:US
Practice Address - Phone:765-962-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003738A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201082950Medicaid
OH0093864Medicaid
IN263670001Medicare PIN
OH0093864Medicaid
IN201082950Medicaid
OHP01297301Medicare PIN