Provider Demographics
NPI:1043568413
Name:JACKSON, DANIELLE NICOLE (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5370 HIGHWAY 92
Mailing Address - Street 2:STE 410
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-2296
Mailing Address - Country:US
Mailing Address - Phone:770-629-4351
Mailing Address - Fax:770-703-3398
Practice Address - Street 1:3360 SHELBY LN
Practice Address - Street 2:SUITE 1010
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-5744
Practice Address - Country:US
Practice Address - Phone:404-344-0274
Practice Address - Fax:404-344-4581
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAOPT002717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist