Provider Demographics
NPI:1487808374
Name:WU, JACQUELINE (OD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:KAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 80992
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91118-8992
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 S LAKE AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3530
Practice Address - Country:US
Practice Address - Phone:626-683-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13630T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist