Healthcare Provider Details

I. General information

NPI: 1568191328
Provider Name (Legal Business Name): JENIFER MARIE PRESNICK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

292 LAFAYETTE ST
STARKE FL
32091-3913
US

IV. Provider business mailing address

292 LAFAYETTE ST
STARKE FL
32091-3913
US

V. Phone/Fax

Practice location:
  • Phone: 904-964-8076
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-E96
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6132
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: