Provider Demographics
NPI:1861440612
Name:WALLER, JENNIFER (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:WALLER
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 1:600 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENLD
Mailing Address - State:IL
Mailing Address - Zip Code:62009-1446
Mailing Address - Country:US
Mailing Address - Phone:217-835-7724
Mailing Address - Fax:217-835-7611
Practice Address - Street 1:2020 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4174
Practice Address - Country:US
Practice Address - Phone:217-698-3030
Practice Address - Fax:217-698-3068
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL410038558OtherRAILROAD MEDICARE - GRD
IL046009087Medicaid
IL410038559OtherRAILROAD MEDICARE - SPFLD