Provider Demographics
NPI:1700570348
Name:AVINA, JENNIFER LILIANA (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LILIANA
Last Name:AVINA
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 1:19341 W SELDON LN
Mailing Address - Street 2:
Mailing Address - City:WADDELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85355-9904
Mailing Address - Country:US
Mailing Address - Phone:623-703-7690
Mailing Address - Fax:
Practice Address - Street 1:2330 N 75TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85035-1200
Practice Address - Country:US
Practice Address - Phone:623-703-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002705152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist