Healthcare Provider Details

I. General information

NPI: 1902804149
Provider Name (Legal Business Name): SALLY BETH JACKULA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 SOUTHWAY DR
SAINT CLOUD MN
56301-9589
US

IV. Provider business mailing address

3112 SOUTHWAY DR
SAINT CLOUD MN
56301-9589
US

V. Phone/Fax

Practice location:
  • Phone: 320-257-4747
  • Fax: 320-262-7118
Mailing address:
  • Phone: 320-257-4747
  • Fax: 320-262-7118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2895
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: