Healthcare Provider Details

I. General information

NPI: 1467078915
Provider Name (Legal Business Name): JACLYN GOODVIN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN TOLLES OD

II. Dates (important events)

Enumeration Date: 06/21/2020
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 E MAIN ST
MILAN MI
48160-1248
US

IV. Provider business mailing address

7 E MAIN ST
MILAN MI
48160-1248
US

V. Phone/Fax

Practice location:
  • Phone: 734-439-2020
  • Fax: 734-439-2047
Mailing address:
  • Phone: 734-439-2020
  • Fax: 734-439-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number006907
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005451
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: