Provider Demographics
NPI:1285775593
Name:CIAK, JENNIFER ANN (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:CIAK
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 1:34771 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152
Mailing Address - Country:US
Mailing Address - Phone:248-476-9792
Mailing Address - Fax:
Practice Address - Street 1:23320 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127
Practice Address - Country:US
Practice Address - Phone:313-562-4733
Practice Address - Fax:313-562-1606
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003863152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2731935Medicaid
MI0H28064OtherBCBS
MI0H28064OtherBCBS
MI2731935Medicaid