Provider Demographics
NPI:1902885734
Name:DAVIS, JACQUELINE GOINGS (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:GOINGS
Last Name:DAVIS
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 1:1160 W BROAD ST
Mailing Address - Street 2:LOWER LIGHTS CHRISTIAN HEALTH CENTER
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1317
Mailing Address - Country:US
Mailing Address - Phone:614-274-1455
Mailing Address - Fax:614-274-2040
Practice Address - Street 1:1160 W BROAD ST
Practice Address - Street 2:LOWER LIGHTS CHRISTIAN HEALTH CENTER
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1317
Practice Address - Country:US
Practice Address - Phone:614-274-1455
Practice Address - Fax:614-274-2040
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3532/403152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0477667Medicaid
OH0477667Medicaid