Basic Information
Provider Information
NPI: 1003014051
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JACKSON
FirstName: JEFFREY
MiddleName: ALAN
NamePrefix: DR.
NameSuffix:  
Credential: O.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3806 S SETON AVE
Address2:  
City: GILBERT
State: AZ
PostalCode: 852979362
CountryCode: US
TelephoneNumber: 4806506794
FaxNumber:  
Practice Location
Address1: 560 N CAMINO MERCADO STE 1
Address2:  
City: CASA GRANDE
State: AZ
PostalCode: 851225759
CountryCode: US
TelephoneNumber: 5204269224
FaxNumber: 5204261554
Other Information
ProviderEnumerationDate: 07/10/2007
LastUpdateDate: 11/09/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X1578AZY Eye and Vision Services ProvidersOptometrist 

ID Information
IDTypeStateIssuerDescription
Z19042305AZ MEDICAID


Home