Healthcare Provider Details

I. General information

NPI: 1518218189
Provider Name (Legal Business Name): JENALYN M JOTIE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE
BOSTON MA
02130-4817
US

IV. Provider business mailing address

150 S HUNTINGTON AVE
BOSTON MA
02130-4817
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-5543
  • Fax: 857-364-6049
Mailing address:
  • Phone: 857-364-5543
  • Fax: 850-452-5549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT14495 TLG
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number907
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: