Provider Demographics
NPI:1033765482
Name:MEYER, JACKELYN THERESA (OD)
Entity Type:Individual
Prefix:
First Name:JACKELYN
Middle Name:THERESA
Last Name:MEYER
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 1:2201 W DOLARWAY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-8228
Mailing Address - Country:US
Mailing Address - Phone:509-925-1000
Mailing Address - Fax:509-925-2474
Practice Address - Street 1:2201 W DOLARWAY RD STE 2
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-8228
Practice Address - Country:US
Practice Address - Phone:509-925-1000
Practice Address - Fax:509-925-2474
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9806152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOD61047749OtherLICENSE