Healthcare Provider Details

I. General information

NPI: 1437721917
Provider Name (Legal Business Name): JACQUELINE SOLANGE KOWAL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 E CAMELBACK RD STE 160
PHOENIX AZ
85016-3947
US

IV. Provider business mailing address

955 W SOUTHERN AVE STE 101
MESA AZ
85210-4903
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-3348
  • Fax: 602-264-2715
Mailing address:
  • Phone: 480-961-1865
  • Fax: 480-893-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0003684
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002627
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: