Provider Demographics
NPI:1962470070
Name:BRANNING, JENNIFER LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:BRANNING
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 1:409 W LUDINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431
Mailing Address - Country:US
Mailing Address - Phone:213-843-4117
Mailing Address - Fax:231-843-7631
Practice Address - Street 1:409 W LUDINGTON AVE
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431
Practice Address - Country:US
Practice Address - Phone:213-843-4117
Practice Address - Fax:231-843-7631
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002994152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1138520001OtherADMINSTAR
MI3305212Medicaid
MI1138520001OtherADMINSTAR
MI3305212Medicaid