Healthcare Provider Details

I. General information

NPI: 1427452325
Provider Name (Legal Business Name): JENNA O'BRIEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E FOREMASTER DR STE 120
ST GEORGE UT
84790-4493
US

IV. Provider business mailing address

1038 S WHITE SANDS DR
WASHINGTON UT
84780-8202
US

V. Phone/Fax

Practice location:
  • Phone: 435-429-1686
  • Fax:
Mailing address:
  • Phone: 435-429-1686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number10115462-9934
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number10115462-9934
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number10115462-9934
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10115462-9934
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: