Provider Demographics
NPI:1194980383
Name:LANE, JENNIFER CHERRY (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHERRY
Last Name:LANE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1056
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23439-1056
Mailing Address - Country:US
Mailing Address - Phone:757-249-1324
Mailing Address - Fax:757-249-1369
Practice Address - Street 1:12130 JEFFERSON AVENUE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602
Practice Address - Country:US
Practice Address - Phone:757-249-1324
Practice Address - Fax:757-249-1369
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001867152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist