Provider Demographics
NPI:1215283312
Name:MUNSON, JACLYN A (OD)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:A
Last Name:MUNSON
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 1:373 W DRAKE RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-2881
Mailing Address - Country:US
Mailing Address - Phone:970-223-7150
Mailing Address - Fax:
Practice Address - Street 1:373 W DRAKE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2881
Practice Address - Country:US
Practice Address - Phone:970-223-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist