Provider Demographics
NPI:1104410927
Name:JENNINGS, MICHAEL JAMES (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 9TH ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-4503
Mailing Address - Country:US
Mailing Address - Phone:806-500-8652
Mailing Address - Fax:
Practice Address - Street 1:1975 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-8388
Practice Address - Country:US
Practice Address - Phone:276-647-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002975152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist