Provider Demographics
NPI:1154586501
Name:LIGHTHIZER, JENNA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MARIE
Last Name:LIGHTHIZER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:JENNA
Other - Middle Name:MARIE
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 N GRAND AVE
Mailing Address - Street 2:NORTHEASTERN STATE UNIVERSITY COLLEGE OF OPTOMETRY
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7017
Mailing Address - Country:US
Mailing Address - Phone:918-458-2109
Mailing Address - Fax:
Practice Address - Street 1:1001 N GRAND AVE
Practice Address - Street 2:NORTHEASTERN STATE UNIVERSITY COLLEGE OF OPTOMETRY
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-458-2109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2609152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist