Healthcare Provider Details

I. General information

NPI: 1831080555
Provider Name (Legal Business Name): JENELLE DETTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENELLE DETTEN

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 KNOTTS POINTE LN STE 107
SUFFOLK VA
23435-1135
US

IV. Provider business mailing address

4312 ALVAH MARTIN WAY
CHESAPEAKE VA
23324-1489
US

V. Phone/Fax

Practice location:
  • Phone: 619-633-5491
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number0618003631
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003631
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: