Healthcare Provider Details

I. General information

NPI: 1154704070
Provider Name (Legal Business Name): JENNIFER L. BALO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER HOLCOMB OD.

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 LONGLEAF PINE PKWY STE 205
SAINT JOHNS FL
32259-7484
US

IV. Provider business mailing address

3735 LONGLEAF PINE PKWY STE 205
SAINT JOHNS FL
32259-7484
US

V. Phone/Fax

Practice location:
  • Phone: 904-713-2020
  • Fax: 888-972-2191
Mailing address:
  • Phone: 904-713-2020
  • Fax: 888-972-2191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 5274
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: