Healthcare Provider Details

I. General information

NPI: 1215546403
Provider Name (Legal Business Name): JACQUELINE THEIS, OD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3721 WESTERRE PKWY STE B
RICHMOND VA
23233-1332
US

IV. Provider business mailing address

10124 W BROAD ST STE E
GLEN ALLEN VA
23060-3330
US

V. Phone/Fax

Practice location:
  • Phone: 804-387-2902
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE THEIS
Title or Position: OWNER
Credential: OD
Phone: 415-404-0557