Provider Demographics
NPI:1124258991
Name:PESEK, JENNIFER (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PESEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:TRUONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 PUBLIC SQ STE 219
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-2301
Mailing Address - Country:US
Mailing Address - Phone:216-621-2815
Mailing Address - Fax:216-621-1745
Practice Address - Street 1:200 PUBLIC SQ STE 219
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-2301
Practice Address - Country:US
Practice Address - Phone:216-621-2815
Practice Address - Fax:216-621-1745
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5905152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9932292Medicare UPIN