Healthcare Provider Details

I. General information

NPI: 1518073246
Provider Name (Legal Business Name): JACQUELINE ROSE ANDERSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE MINIER OD

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

IV. Provider business mailing address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

V. Phone/Fax

Practice location:
  • Phone: 703-784-1631
  • Fax:
Mailing address:
  • Phone: 703-784-1631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2005026113
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: