Provider Demographics
NPI:1629428511
Name:NIEMAN, JENNA (OD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:NIEMAN
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 1:2011 N ROAN ST
Mailing Address - Street 2:SPACE E-6
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-3130
Mailing Address - Country:US
Mailing Address - Phone:423-610-7155
Mailing Address - Fax:
Practice Address - Street 1:7800 MONTGOMERY RD UNIT 5
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-4306
Practice Address - Country:US
Practice Address - Phone:513-793-5970
Practice Address - Fax:513-793-5976
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3348152W00000X
VA0618002513152W00000X
OH006731152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist