Provider Demographics
NPI:1124240569
Name:JACQUIN, DENISE MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:MARIE
Last Name:JACQUIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:BISHOP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7 CROSS COUNTY CT.
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052
Mailing Address - Country:US
Mailing Address - Phone:618-223-0577
Mailing Address - Fax:
Practice Address - Street 1:650 WESLEY DRIVE
Practice Address - Street 2:WOOD RIVER CENTRE
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095
Practice Address - Country:US
Practice Address - Phone:618-258-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist