Provider Demographics
NPI:1700897402
Name:JENNINGS, STEPHEN SELPH (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:SELPH
Last Name:JENNINGS
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 1:2301 HILLIARD RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-4525
Mailing Address - Country:US
Mailing Address - Phone:804-262-5142
Mailing Address - Fax:804-262-6257
Practice Address - Street 1:2301 HILLIARD RD
Practice Address - Street 2:SUITE 3
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-4525
Practice Address - Country:US
Practice Address - Phone:804-262-5142
Practice Address - Fax:804-262-6257
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000068152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010300258Medicaid
VA010300274Medicaid
VA194188OtherANTHEM
VA194180OtherANTHEM
VA580947916Medicare ID - Type UnspecifiedTRAILBLAZER
VA010300258Medicaid
VA010300274Medicaid
VA00X190S01Medicare PIN
VA194180OtherANTHEM
VA5759880002Medicare NSC
VA5759880001Medicare NSC
VAC09956Medicare PIN