Provider Demographics
NPI:1114922036
Name:JACKSON, GREGORY ROBBE (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ROBBE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 DAUPHIN ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-2457
Mailing Address - Country:US
Mailing Address - Phone:251-473-1900
Mailing Address - Fax:251-470-8942
Practice Address - Street 1:2880 DAUPHIN ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-2457
Practice Address - Country:US
Practice Address - Phone:251-473-1900
Practice Address - Fax:251-470-8942
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS662TA239152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51079090OtherBLUE CROSS PROVIDER #
AL5835512OtherAETNA PIN
ALU18672OtherHEALTHSPRING PROVIDER #
AL2210141OtherUNITED HEALTHCARE PROV #
AL2210141OtherUNITED HEALTHCARE PROV #