Provider Demographics
NPI:1154704070
Name:BALO, JENNIFER L (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BALO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HOLCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:901 BLANDING BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-6299
Mailing Address - Country:US
Mailing Address - Phone:904-562-1160
Mailing Address - Fax:
Practice Address - Street 1:901 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-6299
Practice Address - Country:US
Practice Address - Phone:904-562-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 5274152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist