MEDICARE: DR. MIA JEAN JENNINGS 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	3362	FL
2	152W00000X	Optometrist	3178	CO

General Provider Information

NPI Number	:	1588648034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIA JEAN JENNINGS O.D.

Provider Business Mailing Address
First Line	:	1130 LAKE PLAZA DR STE 230
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3595
Country	:	US
Telephone Number	:	719-219-3819
Fax Number	:	719-219-0411

Provider Business Practice Location Address
First Line	:	1130 LAKE PLAZA DR STE 230
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3595
Country	:	US
Telephone Number	:	719-219-3819
Fax Number	:	719-219-0411

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

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	04/13/2016

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