Provider Demographics
NPI:1669153797
Name:PIVARAL, JACKELINE
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:PIVARAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6761 N KENDALL DR APT D201
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-1767
Mailing Address - Country:US
Mailing Address - Phone:305-989-6819
Mailing Address - Fax:
Practice Address - Street 1:13800 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7401
Practice Address - Country:US
Practice Address - Phone:407-599-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6326152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist