Provider Demographics
NPI:1013532480
Name:FIDDLER, JACQUELINE ROSE (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ROSE
Last Name:FIDDLER
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 1:11860 CRANSTON DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-4886
Mailing Address - Country:US
Mailing Address - Phone:901-867-5540
Mailing Address - Fax:
Practice Address - Street 1:11860 CRANSTON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38002-4886
Practice Address - Country:US
Practice Address - Phone:901-867-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020014960152W00000X
TN3700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist