Healthcare Provider Details

I. General information

NPI: 1023417144
Provider Name (Legal Business Name): JACLYN KAY ROBAK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACKIE ROBAK O.D.

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SION FARM UNIT 2
CHRISTIANSTED VI
00820-4493
US

IV. Provider business mailing address

PO BOX 5996
CHRISTIANSTED VI
00823-5996
US

V. Phone/Fax

Practice location:
  • Phone: 340-773-2020
  • Fax: 340-778-0977
Mailing address:
  • Phone: 340-773-2020
  • Fax: 340-778-0977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number055
License Number StateVI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: