Provider Demographics
NPI:1285895946
Name:MALLORY, JENNIFER K (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:K
Last Name:MALLORY
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 1:4886 PORT ROYAL RD STE 150
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-8807
Mailing Address - Country:US
Mailing Address - Phone:931-489-6118
Mailing Address - Fax:
Practice Address - Street 1:4886 PORT ROYAL RD STE 150
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-8807
Practice Address - Country:US
Practice Address - Phone:931-489-6118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT2798152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN35900812Medicare PIN