Provider Demographics
NPI:1053360701
Name:DOFFIN, JACLYN ELIZABETH (OD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ELIZABETH
Last Name:DOFFIN
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 1:4750 WASHINGTON SQ
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3257
Mailing Address - Country:US
Mailing Address - Phone:651-429-3379
Mailing Address - Fax:651-429-8681
Practice Address - Street 1:4750 WASHINGTON SQ
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3257
Practice Address - Country:US
Practice Address - Phone:651-429-3379
Practice Address - Fax:651-429-8681
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2988152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN132424OtherUCARE
MN2202621OtherMEDICA
MN869675600Medicaid
MNHP46401OtherHEALTH PARTNERS
MN1011968OtherPREFERRED ONE
MN612R1STOtherBLUE CROSS BLUE SHIELD
MN869675600Medicaid
MN132424OtherUCARE
P00246882Medicare ID - Type UnspecifiedRAILROAD MEDICARE