Provider Demographics
NPI:1518399849
Name:WANG, JACKIE DIEM (OD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:DIEM
Last Name:WANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DIEM
Other - Middle Name:PHAN
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:837 BROWN TRL
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-7386
Mailing Address - Country:US
Mailing Address - Phone:817-927-6400
Mailing Address - Fax:817-702-6485
Practice Address - Street 1:837 BROWN TRL
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-7386
Practice Address - Country:US
Practice Address - Phone:817-927-6400
Practice Address - Fax:817-702-6485
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8199T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist