Basic Information
| Provider Information | |||||||||
| NPI: | 1619492782 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JENNIFER E. DAVIS, OPTOMETRIST, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VISION TECH OPTOMETRY CENTER, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 221 OSAGE LN STE A | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229809309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409497126 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 221 OSAGE LN STE A | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229809309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409497126 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2017 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5409497126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618001557 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 013398V88 | 01 | VA | MEDICARE PIN | OTHER |