Provider Demographics
NPI:1609305580
Name:MUDD, JACKELLEYN RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:JACKELLEYN
Middle Name:RENEE
Last Name:MUDD
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 1:4366 HIGHWAY H
Mailing Address - Street 2:
Mailing Address - City:SILEX
Mailing Address - State:MO
Mailing Address - Zip Code:63377-2256
Mailing Address - Country:US
Mailing Address - Phone:636-485-7788
Mailing Address - Fax:
Practice Address - Street 1:1310 S BUSINESS 61
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-5221
Practice Address - Country:US
Practice Address - Phone:573-324-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017017079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist