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General NPI Number Information
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NPI Number | 1902804149
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Entity Type | Individual
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Provider Name | SALLY BETH JACKULA OD
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Gender | Female
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Dates
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Enumeration Date | 07/12/2005
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Last Update Date | 03/16/2021
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Provider Practice Location Address
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Address Line | 3112 SOUTHWAY DR
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City | SAINT CLOUD
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State | MN
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Zip | 56301-9589
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Country | US
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Telephone | 320-257-4747
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Fax | 320-262-7118
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Provider Business Mailing Address
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Address Line | 3112 SOUTHWAY DR
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City | SAINT CLOUD
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State | MN
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Zip | 56301-9589
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Country | US
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Telephone | 320-257-4747
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Fax | 320-262-7118
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2895
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License Number State | MN
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