Provider Demographics
NPI:1194755249
Name:PICKEN, JACE HUNTER (OD)
Entity type:Individual
Prefix:DR
First Name:JACE
Middle Name:HUNTER
Last Name:PICKEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 11 ST. N., STE A
Mailing Address - Street 2:PRAIRIE VISION CENTER
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4101
Mailing Address - Country:US
Mailing Address - Phone:701-642-4090
Mailing Address - Fax:701-642-9424
Practice Address - Street 1:315 11 ST. N., STE A
Practice Address - Street 2:PRAIRIE VISION CENTER
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4101
Practice Address - Country:US
Practice Address - Phone:701-642-4090
Practice Address - Fax:701-642-9424
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND694152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60704Medicaid
WAVO3846Medicare UPIN
WA20149Medicare ID - Type Unspecified