Healthcare Provider Details

I. General information

NPI: 1356443261
Provider Name (Legal Business Name): JENNIFER ELAM O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER DUNN O.D.

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3560 PINE GROVE AVE STE 366
PORT HURON MI
48060-1994
US

IV. Provider business mailing address

3560 PINE GROVE AVE STE 366
PORT HURON MI
48060-1994
US

V. Phone/Fax

Practice location:
  • Phone: 502-759-1123
  • Fax:
Mailing address:
  • Phone: 502-759-1123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1607DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1607DT
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1607DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: