Provider Demographics
NPI:1184886731
Name:RAFATI, JENNIFER BRAVE (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BRAVE
Last Name:RAFATI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BRAVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2100 TROY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2595
Mailing Address - Country:US
Mailing Address - Phone:618-656-8888
Mailing Address - Fax:618-656-8920
Practice Address - Street 1:2100 TROY RD STE 104
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2595
Practice Address - Country:US
Practice Address - Phone:618-656-8888
Practice Address - Fax:618-656-8920
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008017085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0460100111Medicaid
MO1184886731Medicaid