Provider Demographics
NPI:1316959679
Name:ALVERSON, JENNIFER (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ALVERSON
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 1:15933 CLAYTON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:1800 AL-77
Practice Address - Street 2:
Practice Address - City:SOUTHSIDE
Practice Address - State:AL
Practice Address - Zip Code:35907-0169
Practice Address - Country:US
Practice Address - Phone:256-442-6200
Practice Address - Fax:256-442-6292
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS879TA440152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009946130Medicaid
AL009946130Medicaid
AL009946130Medicaid