Healthcare Provider Details

I. General information

NPI: 1306739016
Provider Name (Legal Business Name): JACLYN CHARBONNEAU OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2025
Last Update Date: 05/31/2025
Certification Date: 05/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5460 E LA PALMA AVE
ANAHEIM CA
92807-2023
US

IV. Provider business mailing address

6 SHELTON CT
LADERA RANCH CA
92694-0743
US

V. Phone/Fax

Practice location:
  • Phone: 714-463-7500
  • Fax:
Mailing address:
  • Phone: 949-683-2165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35973
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: