Healthcare Provider Details

I. General information

NPI: 1730889320
Provider Name (Legal Business Name): JACQUELINE POWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W WALNUT ST
LEBANON KY
40033-1377
US

IV. Provider business mailing address

PO BOX 207170
DALLAS TX
75320-7170
US

V. Phone/Fax

Practice location:
  • Phone: 270-867-8200
  • Fax: 502-916-3010
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-527-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2353DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: