Provider Demographics
NPI:1093005183
Name:DR MIJA JACKSON LEE PLLC
Entity Type:Organization
Organization Name:DR MIJA JACKSON LEE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIJA
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-572-9555
Mailing Address - Street 1:250 W HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-4415
Mailing Address - Country:US
Mailing Address - Phone:972-572-9555
Mailing Address - Fax:972-572-5505
Practice Address - Street 1:250 W HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-4415
Practice Address - Country:US
Practice Address - Phone:972-572-9555
Practice Address - Fax:972-572-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6034 TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty