Provider Demographics
NPI:1588072003
Name:SHORT, JACQUELYN GAYLE (OD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:GAYLE
Last Name:SHORT
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 1:800 N CLINTON ST
Mailing Address - Street 2:STE D
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-4611
Mailing Address - Country:US
Mailing Address - Phone:419-782-1901
Mailing Address - Fax:
Practice Address - Street 1:7600 KINGSTON PIKE STE 1480
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5632
Practice Address - Country:US
Practice Address - Phone:865-694-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3172152WC0802X, 152WL0500X, 152WP0200X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision