Basic Information
| Provider Information | |||||||||
| NPI: | 1114302346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | JENNA | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 28 BLANDING BLVD | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320732202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042645483 | ||||||||
| FaxNumber: | 9042130515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WV0400X | OPC5174 | FL | N | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152W00000X | OPC5174 | FL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.