Provider Demographics
NPI:1912087909
Name:PATTERSON, JACQUELYN H (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:H
Last Name:PATTERSON
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 1:103 ROHN RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-8073
Mailing Address - Country:US
Mailing Address - Phone:317-831-8480
Mailing Address - Fax:
Practice Address - Street 1:2320 S TIBBS AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-4801
Practice Address - Country:US
Practice Address - Phone:317-241-2019
Practice Address - Fax:317-487-2182
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001954A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200970100Medicaid
IN18001954BOtherCONTROLLED SUBSTANCE CERTIFICATE
INU45555Medicare UPIN
IN18001954BOtherCONTROLLED SUBSTANCE CERTIFICATE