Provider Demographics
NPI:1215319496
Name:WANG, JACQUELYN
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:WANG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8730 VICTORIA PARK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5388
Mailing Address - Country:US
Mailing Address - Phone:707-567-3508
Mailing Address - Fax:
Practice Address - Street 1:4175 S GRAND CANYON DR STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-7155
Practice Address - Country:US
Practice Address - Phone:702-912-4254
Practice Address - Fax:702-847-7624
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15226TLG152W00000X
NV1124152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1215319496Medicaid