Provider Demographics
NPI:1114078235
Name:PHAN, JACLYN T (OD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:T
Last Name:PHAN
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 1:1912 201ST PL SE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8570
Mailing Address - Country:US
Mailing Address - Phone:425-485-6812
Mailing Address - Fax:
Practice Address - Street 1:1912 201ST PL SE
Practice Address - Street 2:SUITE 204
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-8570
Practice Address - Country:US
Practice Address - Phone:425-485-6812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3357152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management