Provider Demographics
NPI:1043662927
Name:OLIVER, JACLYN (OD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:
Last Name:OLIVER
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 1:1562 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2572
Mailing Address - Country:US
Mailing Address - Phone:330-287-4500
Mailing Address - Fax:
Practice Address - Street 1:721 E MILLTOWN RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-1331
Practice Address - Country:US
Practice Address - Phone:330-287-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6557152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1043662927Medicaid
MO067820047Medicare PIN
MO074730048Medicare PIN