Provider Demographics
NPI:1245853563
Name:PENNEY, JILLIAN (OD)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:PENNEY
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 1:14 BEACHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-3552
Mailing Address - Country:US
Mailing Address - Phone:570-262-5627
Mailing Address - Fax:
Practice Address - Street 1:1201 W ELM AVE
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-4600
Practice Address - Country:US
Practice Address - Phone:717-630-2922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOEG003722152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program