Healthcare Provider Details

I. General information

NPI: 1790753879
Provider Name (Legal Business Name): JENNIFER BUTTERFIELD EADDY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/29/2024
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

IV. Provider business mailing address

1228 SHAKER DR
HERNDON VA
20170-2406
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-1600
  • Fax:
Mailing address:
  • Phone: 703-450-6996
  • Fax: 703-450-6996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618000989
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000989
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: