Provider Demographics
NPI:1952318537
Name:BOCKENSTEDT, JENNELL JOE (OD)
Entity Type:Individual
Prefix:
First Name:JENNELL
Middle Name:JOE
Last Name:BOCKENSTEDT
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 1:48 W ROMIE LANE
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-8314
Mailing Address - Country:US
Mailing Address - Phone:831-424-0834
Mailing Address - Fax:831-424-4994
Practice Address - Street 1:48 W ROMIE LANE
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-8314
Practice Address - Country:US
Practice Address - Phone:831-424-0834
Practice Address - Fax:831-424-4994
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12790152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12790Medicare ID - Type Unspecified