Provider Demographics
NPI:1780242883
Name:YI, JACQUELYN JIMIN (OD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:JIMIN
Last Name:YI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:JIMIN
Other - Last Name:YI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:4117 E BELLEVUE ST APT 7
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4532
Mailing Address - Country:US
Mailing Address - Phone:520-208-0857
Mailing Address - Fax:
Practice Address - Street 1:7046 E GOLF LINKS RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85730-1000
Practice Address - Country:US
Practice Address - Phone:520-790-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002379152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program