Provider Demographics
NPI:1184101602
Name:STODDARD, JENNA ELISE (OD)
Entity type:Individual
Prefix:DR
First Name:JENNA
Middle Name:ELISE
Last Name:STODDARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12 FAIRFAX ST SE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-3616
Mailing Address - Country:US
Mailing Address - Phone:703-777-1299
Mailing Address - Fax:
Practice Address - Street 1:1524 NC 24-87
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:NC
Practice Address - Zip Code:28326-9424
Practice Address - Country:US
Practice Address - Phone:910-223-5410
Practice Address - Fax:910-223-5119
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2688152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2688OtherNORTH CAROLINA OPTOMETRY LICENSE