Provider Demographics
NPI:1962790055
Name:BRANDON, JENNIFER J (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:BRANDON
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 1:4021 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2413
Mailing Address - Country:US
Mailing Address - Phone:513-245-9700
Mailing Address - Fax:
Practice Address - Street 1:9593 COLERAIN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45251-2003
Practice Address - Country:US
Practice Address - Phone:513-245-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6075-T2990152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050746Medicaid
OH6075-T2990OtherOHIO OPTOMETRY LICENSE