Provider Demographics
NPI:1619718939
Name:CHAN, JENNIFER (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 DEPTFORD CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-5633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1907 DEPTFORD CENTER RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-5633
Practice Address - Country:US
Practice Address - Phone:856-232-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00728100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist