Provider Demographics
NPI:1558688499
Name:KOWAL, JACQUELINE M (RO)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:M
Last Name:KOWAL
Suffix:
Gender:F
Credentials:RO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 NEW KENT HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:QUINTON
Mailing Address - State:VA
Mailing Address - Zip Code:23141
Mailing Address - Country:US
Mailing Address - Phone:804-307-4150
Mailing Address - Fax:
Practice Address - Street 1:2520 NEW KENT HIGHWAY
Practice Address - Street 2:
Practice Address - City:QUINTON
Practice Address - State:VA
Practice Address - Zip Code:23141
Practice Address - Country:US
Practice Address - Phone:804-307-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101002137156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician