Individual
DR. SALLY BETH JACKULA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
3112 SOUTHWAY DR, SAINT CLOUD, MN 56301-9589
(320) 257-4747
(320) 262-7118
Mailing address
3112 SOUTHWAY DR, SAINT CLOUD, MN 56301-9589
(320) 257-4747
(320) 262-7118
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2895
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
125T6JA
BCBS
MN
05
—
126382000
—
MN
01
—
141351
UCARE
MN
01
—
207837
207837
MN
01
—
22-01872
MEDICA
MN
01
—
964141032721
P-1
MN
01
—
HP37041
HP
MN
Enumeration date
07/12/2005
Last updated
03/16/2021
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