Provider Demographics
NPI:1902804149
Name:JACKULA, SALLY BETH (OD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:BETH
Last Name:JACKULA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3112 SOUTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9589
Mailing Address - Country:US
Mailing Address - Phone:320-257-4747
Mailing Address - Fax:320-262-7118
Practice Address - Street 1:3112 SOUTHWAY DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-9589
Practice Address - Country:US
Practice Address - Phone:320-257-4747
Practice Address - Fax:320-262-7118
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2895152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN207837Other207837
MN22-01872OtherMEDICA
MN125T6JAOtherBCBS
MN126382000Medicaid
MN141351OtherUCARE
MN964141032721OtherP-1
MNHP37041OtherHP