Healthcare Provider Details

I. General information

NPI: 1982132767
Provider Name (Legal Business Name): JENNA DEWALD OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3373 PRINCETON RD STE 121
HAMILTON OH
45011-7963
US

IV. Provider business mailing address

2411 S CANYON WOODS LN APT 308
SPOKANE WA
99224-5722
US

V. Phone/Fax

Practice location:
  • Phone: 513-893-2900
  • Fax:
Mailing address:
  • Phone: 513-893-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6541
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: