Healthcare Provider Details

I. General information

NPI: 1043662927
Provider Name (Legal Business Name): JACLYN OLIVER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 E MILLTOWN RD
WOOSTER OH
44691-1331
US

IV. Provider business mailing address

1562 ROSEWOOD DR
WOOSTER OH
44691-2572
US

V. Phone/Fax

Practice location:
  • Phone: 330-287-4500
  • Fax:
Mailing address:
  • Phone: 330-287-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number6557
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6557
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: