Provider Demographics
NPI:1922290949
Name:MONCADA, JENNIFER M (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:MONCADA
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 1:1518 W AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-3725
Mailing Address - Country:US
Mailing Address - Phone:985-652-4097
Mailing Address - Fax:985-652-9917
Practice Address - Street 1:1518 W AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-3725
Practice Address - Country:US
Practice Address - Phone:985-652-4097
Practice Address - Fax:985-652-9917
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4360152W00000X
MA4634152W00000X
LA1572-604T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0000025360OtherRI BCBS
MAAA96447OtherHARVARD PILGRIM
LA1887897Medicaid
MA0715484Medicaid
MA0715484Medicaid
MA000244301Medicare PIN