Healthcare Provider Details

I. General information

NPI: 1629428511
Provider Name (Legal Business Name): JENNA NIEMAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 MONTGOMERY RD UNIT 5
CINCINNATI OH
45236-4306
US

IV. Provider business mailing address

2011 N ROAN ST SPACE E-6
JOHNSON CITY TN
37601-3130
US

V. Phone/Fax

Practice location:
  • Phone: 513-793-5970
  • Fax: 513-793-5976
Mailing address:
  • Phone: 423-610-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3348
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002513
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number006731
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: