MEDICARE: JENNIFER HAVRILLA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0002925	CO

General Provider Information

NPI Number	:	1134480973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER HAVRILLA O.D.

Provider Business Mailing Address
First Line	:	425 CROWS NEST CT
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3118
Country	:	US
Telephone Number	:	970-629-1325
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 CROWS NEST CT
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3118
Country	:	US
Telephone Number	:	970-629-1325
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2012
Last Update Date	:	11/24/2016

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