Provider Demographics
NPI:1154368736
Name:KENNY, JAIME LARSEN (OD)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:LARSEN
Last Name:KENNY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JAIME
Other - Middle Name:LARSEN
Other - Last Name:VAN FOSSAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1028 RIDGE RD
Mailing Address - Street 2:STE 104
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2975
Mailing Address - Country:US
Mailing Address - Phone:315-445-7465
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:1028 RIDGE RD STE 104
Practice Address - Street 2:EMPIRE VISION CENTERS
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2973
Practice Address - Country:US
Practice Address - Phone:585-872-2200
Practice Address - Fax:585-288-8998
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U91993Medicare UPIN
NYDD2155Medicare ID - Type Unspecified