Provider Demographics
NPI:1649634478
Name:JENNIFER DENHARTOG OD LLC
Entity type:Organization
Organization Name:JENNIFER DENHARTOG OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OD
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DENHARTOG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:515-512-1444
Mailing Address - Street 1:12695 UNIVERSITY AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8217
Mailing Address - Country:US
Mailing Address - Phone:515-512-1444
Mailing Address - Fax:515-512-1440
Practice Address - Street 1:12695 UNIVERSITY AVE STE 170
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325
Practice Address - Country:US
Practice Address - Phone:515-512-1444
Practice Address - Fax:515-512-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1229344Medicaid