Provider Demographics
NPI:1518073246
Name:ANDERSON, JACQUELINE ROSE (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ROSE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:MINIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:8901 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-0004
Mailing Address - Country:US
Mailing Address - Phone:301-295-0213
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0004
Practice Address - Country:US
Practice Address - Phone:301-295-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005026113152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO317327104Medicaid
MO317327104Medicaid
MO258797473Medicare ID - Type Unspecified