Provider Demographics
NPI:1689015901
Name:THEIS, JACQUELINE MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIE
Last Name:THEIS
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 1:1001 E BYRD ST APT 6329
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-4292
Mailing Address - Country:US
Mailing Address - Phone:804-387-2902
Mailing Address - Fax:
Practice Address - Street 1:3721 WESTERRE PKWY STE B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-1332
Practice Address - Country:US
Practice Address - Phone:804-387-2902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14703TLG152W00000X
VA0618002840152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist