Provider Demographics
NPI:1578564464
Name:RHEAULT, JACQUELINE A (OD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:RHEAULT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:R
Other - Last Name:LIPSY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:248 PLEASANT ST
Mailing Address - Street 2:STE 1600
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2588
Mailing Address - Country:US
Mailing Address - Phone:603-224-2020
Mailing Address - Fax:603-228-0248
Practice Address - Street 1:248 PLEASANT ST
Practice Address - Street 2:STE 1600
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2588
Practice Address - Country:US
Practice Address - Phone:603-224-2020
Practice Address - Fax:603-228-0248
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410038181OtherMEDICARE RR
NH0900169YONH01OtherANTHEM
NH30010905Medicaid
NH312992OtherCIGNA
NH30010905Medicaid
NHRE4245Medicare PIN