=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922043496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER MARSHALL JAIKARAN O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 06/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3975 OLD MILTON PKWY
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30005-4467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-624-7766
-----------------------------------------------------
Fax | 678-624-7775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8614 WESTWOOD CENTER DR FL 9
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-2442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-847-8899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC 4030
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT 002111
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------