Provider Demographics
NPI:1104178094
Name:POKUSA, JACQUELINE E (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:E
Last Name:POKUSA
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 1:6677 RICHMOND HWY
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-6647
Mailing Address - Country:US
Mailing Address - Phone:703-535-5568
Mailing Address - Fax:
Practice Address - Street 1:6677 RICHMOND HWY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-6647
Practice Address - Country:US
Practice Address - Phone:703-535-5568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4941152WP0200X
MDTA2382152WP0200X
VA0618002276152WP0200X
DCOP1000276152WP0200X
PAOEG003023152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOEG003023OtherPA LICENSE NUMBER
MDTA2382OtherBOARD OF EXAMINERS IN OPTOMETRY, LICENSE NUMBER
MA4941OtherMASSACHUSETTS BOARD OF OPTOMETRY, LICENSE NUMBER
DCOP1000276OtherBOARD OF OPTOMETRY, LICENSE NUMBER
VA0618002276OtherBOARD OF OPTOMETRY, LICENSE NUMBER