Sally Beth Jackula, OD

Primary specialty

OptometristTaxonomy code 152W00000X

License

2895 Issued in MN

Practice address

3112 Southway Dr
Saint Cloud, MN 56301-9589

Phone

(320) 257-4747

Fax

(320) 262-7118

NPI assigned

Jul 12, 2005

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 7

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Iris Vision Care, LLC.

  • Clinic/Center
  • Saint Cloud, MN
  • NPI 1679708887
  Medicare reassignment NPD Authorized official
• Midwest Vision Centers Inc

  • Optician
  • Virginia, MN
  • NPI 1336352475
  NPD (past)
• Patjac, Inc.

  • Eyewear Supplier
  • Saint Cloud, MN
  • NPI 1033118302
  NPD (past)
• Quarry Optical, Inc.

  • Optometrist
  • Waite Park, MN
  • NPI 1811395544
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121126400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1615852800000",
    "number": "1902804149",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3112 SOUTHWAY DR",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563019589",
            "telephone_number": "320-257-4747",
            "fax_number": "320-262-7118"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3112 SOUTHWAY DR",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563019589",
            "telephone_number": "320-257-4747",
            "fax_number": "320-262-7118"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKULA",
        "first_name": "SALLY",
        "middle_name": "BETH",
        "name_prefix": "Dr.",
        "credential": "OD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2005-07-12",
        "last_updated": "2021-03-16",
        "certification_date": "2021-03-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "MN",
            "license": "2895",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "207837",
            "identifier": "207837",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA",
            "identifier": "22-01872",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "125T6JA",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "126382000",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCARE",
            "identifier": "141351",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "P-1",
            "identifier": "964141032721",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HP",
            "identifier": "HP37041",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Satchel James Iten, APRN, CNP
• Carol Jean Iverson, CRNA
• Stacy Marie Jackels
• Brianna Jamilla Jackson
• Robert Jack Jackula, OD
• Michael Jacob
• Gregory Jacobs, DO
• Jaclyn N Jacobs, M.D.
• Jessica Jacobs
• Rebekka Jacobs, MD

• Optometrist in Saint Cloud, MN
• Providers in Saint Cloud, MN by specialty
• Optometrist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 16, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.