Healthcare Provider Details

I. General information

NPI: 1033990080
Provider Name (Legal Business Name): JACQUELINE VANESSA ESCOBAR OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N STONE ST
DELAND FL
32720-3256
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 386-734-1766
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: