Provider Demographics
NPI:1467078915
Name:GOODVIN, JACLYN (OD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GOODVIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:TOLLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:7 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-1248
Mailing Address - Country:US
Mailing Address - Phone:734-439-2020
Mailing Address - Fax:734-439-2047
Practice Address - Street 1:7 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1248
Practice Address - Country:US
Practice Address - Phone:734-439-2020
Practice Address - Fax:734-439-2047
Is Sole Proprietor?:No
Enumeration Date:2020-06-21
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH006907152W00000X
MI4901005451152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist