Healthcare Provider Details

I. General information

NPI: 1285979377
Provider Name (Legal Business Name): JENNA MARIE DALE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA MARIE LIECHTY O.D.

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 S. WOODCREST DRIVE PRECISION EYE GROUP
BLOOMINGTON IN
47401
US

IV. Provider business mailing address

322 S. WOODCREST DRIVE PRECISION EYE GROUP
BLOOMINGTON IN
47401
US

V. Phone/Fax

Practice location:
  • Phone: 812-332-2020
  • Fax:
Mailing address:
  • Phone: 812-332-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number18003771A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3035
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number18003771A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003771A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: