Provider Demographics
NPI:1922143635
Name:LOCASCIO, JACK V (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:V
Last Name:LOCASCIO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 SW 336TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-2848
Mailing Address - Country:US
Mailing Address - Phone:253-874-8125
Mailing Address - Fax:253-874-8184
Practice Address - Street 1:2314 SW 336TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023-2848
Practice Address - Country:US
Practice Address - Phone:253-874-8125
Practice Address - Fax:253-874-8184
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1497152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2021376Medicaid
U20873Medicare UPIN
WA2021376Medicaid