Provider Demographics
NPI:1528066776
Name:JACKULA, ROBERT JACK (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JACK
Last Name:JACKULA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3706
Mailing Address - Country:US
Mailing Address - Phone:320-252-2021
Mailing Address - Fax:320-252-7416
Practice Address - Street 1:4118 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3706
Practice Address - Country:US
Practice Address - Phone:320-252-2021
Practice Address - Fax:320-252-7416
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1574152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN964141021424OtherP-1
MN04563JAOtherBCBS
MN30610OtherCOLE
MN22-11984OtherMEDICA
MN111564OtherUCARE
MNHP25479OtherHP
U05491Medicare UPIN