Healthcare Provider Details

I. General information

NPI: 1578555884
Provider Name (Legal Business Name): JENNIFER MAZZOLA SORTOR O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2433 OAK VALLEY DR SUITE 300
ANN ARBOR MI
48103-7602
US

IV. Provider business mailing address

2433 OAK VALLEY DR SUITE 300
ANN ARBOR MI
48103-7602
US

V. Phone/Fax

Practice location:
  • Phone: 734-994-0100
  • Fax: 734-994-9625
Mailing address:
  • Phone: 734-994-0100
  • Fax: 734-994-9625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004033
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4901004033
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number4901004033
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number4901004033
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number4901004033
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: