Provider Demographics
NPI:1922353390
Name:FORDYCE, JACLYN (OD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:FORDYCE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:171 WEXFORD-BAYNE RD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090
Mailing Address - Country:US
Mailing Address - Phone:724-933-7699
Mailing Address - Fax:724-933-7696
Practice Address - Street 1:171 WEXFORD-BAYNE RD.
Practice Address - Street 2:SUITE 102
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090
Practice Address - Country:US
Practice Address - Phone:724-933-7699
Practice Address - Fax:724-933-7696
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist