Provider Demographics
NPI:1306739016
Name:CHARBONNEAU, JACLYN (OD)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:
Last Name:CHARBONNEAU
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 1:6 SHELTON CT
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0743
Mailing Address - Country:US
Mailing Address - Phone:949-683-2165
Mailing Address - Fax:
Practice Address - Street 1:5460 E LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-2023
Practice Address - Country:US
Practice Address - Phone:714-463-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-31
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35973152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist