Healthcare Provider Details

I. General information

NPI: 1649443623
Provider Name (Legal Business Name): JENNIFER STEVENS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 GRANDVIEW AVE SUITE 3
HONESDALE PA
18431-1163
US

IV. Provider business mailing address

273 GRANDVIEW AVE SUITE 3
HONESDALE PA
18431-1163
US

V. Phone/Fax

Practice location:
  • Phone: 570-253-8840
  • Fax: 570-253-8860
Mailing address:
  • Phone: 570-253-8840
  • Fax: 570-253-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JENNIFER STEVENS
Title or Position: OPTOMERTRIST
Credential: OD
Phone: 570-253-8840