Provider Demographics
NPI:1356897284
Name:JENNESS, JONATHAN (OD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:JENNESS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3144 EL CAMINO REAL STE 202
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2194
Mailing Address - Country:US
Mailing Address - Phone:760-434-3314
Mailing Address - Fax:760-434-5624
Practice Address - Street 1:3144 EL CAMINO REAL STE 202
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2194
Practice Address - Country:US
Practice Address - Phone:760-434-3314
Practice Address - Fax:760-434-5624
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33667152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist