Provider Demographics
NPI:1760709125
Name:HONSTROM, JACQUELINE CARYN
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CARYN
Last Name:HONSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 N MAIN ST
Mailing Address - Street 2:PO BOX 39
Mailing Address - City:WAHKON
Mailing Address - State:MN
Mailing Address - Zip Code:56386-4401
Mailing Address - Country:US
Mailing Address - Phone:320-495-3500
Mailing Address - Fax:320-495-3502
Practice Address - Street 1:270 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WAHKON
Practice Address - State:MN
Practice Address - Zip Code:56386-4401
Practice Address - Country:US
Practice Address - Phone:320-495-3500
Practice Address - Fax:320-495-3502
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2148152W00000X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1164525044Medicaid