Provider Demographics
NPI:1689863623
Name:JENNIFER DAMICO OCONNOR
Entity type:Organization
Organization Name:JENNIFER DAMICO OCONNOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DAMICO
Authorized Official - Last Name:OCONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:508-867-3755
Mailing Address - Street 1:355 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH BROOKFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01535
Mailing Address - Country:US
Mailing Address - Phone:508-867-3755
Mailing Address - Fax:508-867-7832
Practice Address - Street 1:355 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH BROOKFIELD
Practice Address - State:MA
Practice Address - Zip Code:01535
Practice Address - Country:US
Practice Address - Phone:508-867-3755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3785152W00000X
MA3786332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9777385Medicaid
MA9777385Medicaid