Provider Demographics
NPI:1073180741
Name:JACKSON, WALTER LEE II (OD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:LEE
Last Name:JACKSON
Suffix:II
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2616 WARM SPRINGS ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5323
Mailing Address - Country:US
Mailing Address - Phone:706-507-7530
Mailing Address - Fax:706-221-9797
Practice Address - Street 1:2616 WARM SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5323
Practice Address - Country:US
Practice Address - Phone:706-507-7530
Practice Address - Fax:706-221-9797
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-E78152W00000X, 152WL0500X, 152WX0102X
ALS-E78-TA-C17152W00000X, 152WL0500X, 152WX0102X
GAOPT003364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision