Healthcare Provider Details

I. General information

NPI: 1184101602
Provider Name (Legal Business Name): JENNA ELISE STODDARD OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2848 NILES RD
SAINT JOSEPH MI
49085-3352
US

IV. Provider business mailing address

2848 NILES RD
SAINT JOSEPH MI
49085-3352
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-3300
  • Fax: 269-428-5005
Mailing address:
  • Phone: 269-428-3300
  • Fax: 269-428-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2688
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005923
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: