Provider Demographics
NPI:1619082062
Name:CLAIR-HORN, JACQUELINE ROSE (OD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROSE
Last Name:CLAIR-HORN
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 1:235 E BARNETT RD STE 108
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-7903
Mailing Address - Country:US
Mailing Address - Phone:541-779-3797
Mailing Address - Fax:541-779-3797
Practice Address - Street 1:235 E BARNETT RD STE 108
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7903
Practice Address - Country:US
Practice Address - Phone:541-779-3797
Practice Address - Fax:541-779-3797
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3092T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269031Medicaid
OR117112Medicare PIN
OR269031Medicaid