Basic Information
| Provider Information | |||||||||
| NPI: | 1417335175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALAQUINEZ | ||||||||
| FirstName: | JACKLYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205B W WATER ST | ||||||||
| Address2: | |||||||||
| City: | KERRVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780284252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308962600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 10TH ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | FLORESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781143197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8303937744 | ||||||||
| FaxNumber: | 8303937703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 01/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 8641TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 351700501 | 05 | TX | MEDICAID |