Basic Information
Provider Information | |||||||||
NPI: | 1922043496 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAIKARAN | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | MARSHALL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MARSHALL | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | KAREN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | O.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
Address2: |   | ||||||||
City: | VIENNA | ||||||||
State: | VA | ||||||||
PostalCode: | 221823970 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038478899 | ||||||||
FaxNumber: | 8667954020 | ||||||||
Practice Location | |||||||||
Address1: | 3975 OLD MILTON PKWY | ||||||||
Address2: |   | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300054467 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6786247766 | ||||||||
FaxNumber: | 6786247775 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC 4030 | FL | N |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | OPT 002111 | GA | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 304425559A | 05 | GA |   | MEDICAID |