Provider Demographics
NPI:1982132767
Name:DEWALD, JENNA (OD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:DEWALD
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 1:2411 S CANYON WOODS LN
Mailing Address - Street 2:APT 308
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-5722
Mailing Address - Country:US
Mailing Address - Phone:513-893-2900
Mailing Address - Fax:
Practice Address - Street 1:3373 PRINCETON RD STE 121
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-7963
Practice Address - Country:US
Practice Address - Phone:513-893-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6541152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist