Provider Demographics
NPI:1851396170
Name:DEMOTT-CAMP, JENNIFER (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:DEMOTT-CAMP
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 1:217 JACKIE FRANK RD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:15478-1501
Mailing Address - Country:US
Mailing Address - Phone:724-564-1811
Mailing Address - Fax:724-564-0803
Practice Address - Street 1:1500 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-5864
Practice Address - Country:US
Practice Address - Phone:724-228-5610
Practice Address - Fax:724-222-7565
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0EG000199152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA016023160004Medicaid
PA01602316006Medicaid
PA01602316003Medicaid
U63298Medicare UPIN
PA01602316006Medicaid
PA06883RNFMedicare PIN
DE886533Medicare ID - Type UnspecifiedPERSONAL NUMBER