Provider Demographics
NPI:1003125535
Name:CHILDERS AND JACKSON FAMILY EYE CARE INC.
Entity Type:Organization
Organization Name:CHILDERS AND JACKSON FAMILY EYE CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:RM
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-238-9407
Mailing Address - Street 1:723 FALLS BLVD S
Mailing Address - Street 2:STE A
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-3508
Mailing Address - Country:US
Mailing Address - Phone:870-238-9407
Mailing Address - Fax:870-238-4320
Practice Address - Street 1:723 FALLS BLVD S
Practice Address - Street 2:STE A
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-3508
Practice Address - Country:US
Practice Address - Phone:870-238-9407
Practice Address - Fax:870-238-4320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-01
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186236722Medicaid