Provider Demographics
NPI:1124711437
Name:CROSSMAN, JENNIFER ELLEN (LDO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELLEN
Last Name:CROSSMAN
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16375 MERCHANTS LN
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-5655
Mailing Address - Country:US
Mailing Address - Phone:540-413-3141
Mailing Address - Fax:540-644-0719
Practice Address - Street 1:16375 MERCHANTS LN
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-5655
Practice Address - Country:US
Practice Address - Phone:540-413-3141
Practice Address - Fax:540-644-0719
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101003906156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician