Individual
DR. JENNIFER WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
2020 W ILES AVE, SPRINGFIELD, IL 62704-4174
(217) 698-3030
(217) 698-3068
Mailing address
600 S 8TH ST, BENLD, IL 62009-1446
(217) 835-7724
(217) 835-7611
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046009087
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
046009087
—
IL
01
—
410038558
RAILROAD MEDICARE - GRD
IL
01
—
410038559
RAILROAD MEDICARE - SPFLD
IL
Enumeration date
05/04/2006
Last updated
02/03/2023
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