Provider Demographics
NPI:1205067139
Name:CAINE, JENNIFER LEE (O D)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:CAINE
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5455 HARRISON PARK LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-2245
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:3733 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1501
Practice Address - Country:US
Practice Address - Phone:317-254-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200951300Medicaid