Healthcare Provider Details

I. General information

NPI: 1861440612
Provider Name (Legal Business Name): JENNIFER WALLER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

IV. Provider business mailing address

600 S 8TH ST
BENLD IL
62009-1446
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-3030
  • Fax: 217-698-3068
Mailing address:
  • Phone: 217-835-7724
  • Fax: 217-835-7611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009087
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: