Provider Demographics
NPI:1134330475
Name:TRAVIS, JENNIFER LYNNE (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNNE
Last Name:TRAVIS
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 1:3357 HANNAH CT
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-1385
Mailing Address - Country:US
Mailing Address - Phone:404-783-0242
Mailing Address - Fax:
Practice Address - Street 1:3625 DALLAS HWY SW
Practice Address - Street 2:SUITE 660
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-5912
Practice Address - Country:US
Practice Address - Phone:770-590-8951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002143152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist