Provider Demographics
NPI:1194721241
Name:GANNON, JENNIFER SAKURA (OD, FAAO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SAKURA
Last Name:GANNON
Suffix:
Gender:F
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 HALL
Mailing Address - Street 2:
Mailing Address - City:CUT BANK
Mailing Address - State:MT
Mailing Address - Zip Code:59427-9220
Mailing Address - Country:US
Mailing Address - Phone:406-336-2657
Mailing Address - Fax:
Practice Address - Street 1:BLACKFEET COMMUNITY HOSPITAL EYE CLINIC
Practice Address - Street 2:HOPSITAL CIRCLE
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417
Practice Address - Country:US
Practice Address - Phone:406-338-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK233152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist