Provider Demographics
NPI:1568699064
Name:SMITH, JACQUELYN ELIZABETH (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:ELIZABETH
Last Name:SMITH
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 1:655 N WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 N TOPEKA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2810
Practice Address - Country:US
Practice Address - Phone:316-866-2000
Practice Address - Fax:316-866-2084
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1851152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist