Provider Demographics
NPI:1033745468
Name:NGUYEN, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 WALTERS RD
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-3043
Mailing Address - Country:US
Mailing Address - Phone:707-234-5564
Mailing Address - Fax:707-666-6070
Practice Address - Street 1:350 WALTERS RD
Practice Address - Street 2:
Practice Address - City:SUISUN CITY
Practice Address - State:CA
Practice Address - Zip Code:94585-3043
Practice Address - Country:US
Practice Address - Phone:510-854-9876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist