Provider Demographics
NPI:1063898161
Name:ROUSE, JACLYN DEANN (OD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:DEANN
Last Name:ROUSE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:DEANN
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:410 NORTH M STREET
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743
Mailing Address - Country:US
Mailing Address - Phone:580-326-7561
Mailing Address - Fax:580-326-7564
Practice Address - Street 1:410 NORTH M STREET
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743
Practice Address - Country:US
Practice Address - Phone:580-326-7561
Practice Address - Fax:580-326-7564
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2855152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist