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NPI Code Detail

MEDICARE: MISS JENNIFER LYNN DEGON ABOC

MEDICARE: MISS JENNIFER LYNN DEGON ABOC
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
1156FX1202XOptometric Technician

General Provider Information

NPI Number : 1700192937
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS JENNIFER LYNN DEGON ABOC
Provider Business Mailing Address
First Line : 306 N ELLEN ST
Second Line :
City : DIXON
State : MO
Zip : 65459-6307
Country : US
Telephone Number : 573-596-0048
Fax Number : 573-596-0716
Provider Business Practice Location Address
First Line : 126 MISSOURI AVE
Second Line :
City : FORT LEONARD WOOD
State : MO
Zip : 65473-8952
Country : US
Telephone Number : 573-596-0048
Fax Number : 573-596-0716
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/25/2010
Last Update Date : 08/25/2010

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