Provider Demographics
NPI:1336185172
Name:WEAVER, JENNIFER LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:WEAVER
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 1:4760 STONE VIEW CT
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-7966
Mailing Address - Country:US
Mailing Address - Phone:740-881-5373
Mailing Address - Fax:
Practice Address - Street 1:1150 POLARIS PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240-2024
Practice Address - Country:US
Practice Address - Phone:614-433-7357
Practice Address - Fax:614-847-4138
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4038291Medicare ID - Type Unspecified
OHU93269Medicare UPIN