Provider Demographics
NPI:1194089060
Name:WRAY, JACLYN MAY (OD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MAY
Last Name:WRAY
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 1:2832 SAGE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3105
Mailing Address - Country:US
Mailing Address - Phone:510-292-8101
Mailing Address - Fax:
Practice Address - Street 1:2080 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1916
Practice Address - Country:US
Practice Address - Phone:303-651-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2918152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist