Healthcare Provider Details

I. General information

NPI: 1215319496
Provider Name (Legal Business Name): JACQUELYN WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4175 S GRAND CANYON DR STE 105
LAS VEGAS NV
89147-7155
US

IV. Provider business mailing address

8730 VICTORIA PARK ST
LAS VEGAS NV
89148-5388
US

V. Phone/Fax

Practice location:
  • Phone: 702-912-4254
  • Fax: 702-847-7624
Mailing address:
  • Phone: 707-567-3508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number15226TLG
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1124
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: