Provider Demographics
NPI:1891952453
Name:JACQUELYN POWERS OD PC
Entity Type:Organization
Organization Name:JACQUELYN POWERS OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-527-5210
Mailing Address - Street 1:3539 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4811
Mailing Address - Country:US
Mailing Address - Phone:918-527-5210
Mailing Address - Fax:405-364-3269
Practice Address - Street 1:3539 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4811
Practice Address - Country:US
Practice Address - Phone:185-275-2109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2496152W00000X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200110110Medicaid
OK200110110AMedicaid