Basic Information
| Provider Information | |||||||||
| NPI: | 1104178094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POKUSA | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6677 RICHMOND HWY | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223066647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035355568 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6677 RICHMOND HWY | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223066647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035355568 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WP0200X | 4941 | MA | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WP0200X | TA2382 | MD | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WP0200X | 0618002276 | VA | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WP0200X | OP1000276 | DC | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152W00000X | OEG003023 | PA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | OEG003023 | 01 | PA | PA LICENSE NUMBER | OTHER | TA2382 | 01 | MD | BOARD OF EXAMINERS IN OPTOMETRY, LICENSE NUMBER | OTHER | 4941 | 01 | MA | MASSACHUSETTS BOARD OF OPTOMETRY, LICENSE NUMBER | OTHER | OP1000276 | 01 | DC | BOARD OF OPTOMETRY, LICENSE NUMBER | OTHER | 0618002276 | 01 | VA | BOARD OF OPTOMETRY, LICENSE NUMBER | OTHER |