Provider Demographics
NPI:1154896363
Name:TYRA, JACQUELYN (OD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:TYRA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21735 PINEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-2300
Mailing Address - Country:US
Mailing Address - Phone:703-304-2459
Mailing Address - Fax:
Practice Address - Street 1:43490 YUKON DR STE 200
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-7315
Practice Address - Country:US
Practice Address - Phone:703-724-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002779152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist