Healthcare Provider Details

I. General information

NPI: 1114078235
Provider Name (Legal Business Name): JACLYN T PHAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 11/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 201ST PL SE SUITE 204
BOTHELL WA
98012-8570
US

IV. Provider business mailing address

1912 201ST PL SE SUITE 204
BOTHELL WA
98012-8570
US

V. Phone/Fax

Practice location:
  • Phone: 425-485-6812
  • Fax:
Mailing address:
  • Phone: 425-485-6812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3357
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: