Provider Demographics
NPI:1073669834
Name:JACKSONEYE SC
Entity Type:Organization
Organization Name:JACKSONEYE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:ALIN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-356-0700
Mailing Address - Street 1:300 N MILWAUKEE AVE
Mailing Address - Street 2:SUITE L
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046
Mailing Address - Country:US
Mailing Address - Phone:847-356-0700
Mailing Address - Fax:847-356-0700
Practice Address - Street 1:300 N MILWAUKEE AVE
Practice Address - Street 2:SUITE L
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-356-0700
Practice Address - Fax:847-356-0757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004932263OtherBCBS
IL208201Medicare ID - Type Unspecified