MEDICARE: JACKLYN LY OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC6845	FL

General Provider Information

NPI Number	:	1902779465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKLYN LY OD

Provider Business Mailing Address
First Line	:	11794 E COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32817-4626
Country	:	US
Telephone Number	:	407-904-4431
Fax Number	:

Provider Business Practice Location Address
First Line	:	11794 E COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32817-4626
Country	:	US
Telephone Number	:	407-904-4431
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2025
Last Update Date	:	01/20/2026

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Directions to “ JACKLYN LY OD” Practice Location

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