Provider Demographics
NPI:1144387333
Name:MICHAELIS JACKSON & ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MICHAELIS JACKSON & ASSOCIATES, LLC
Other - Org Name:JACKSON VISION & LASER CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAELIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-351-8900
Mailing Address - Street 1:2800 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1087
Mailing Address - Country:US
Mailing Address - Phone:618-351-8900
Mailing Address - Fax:618-351-0076
Practice Address - Street 1:500 LINCOLN DR
Practice Address - Street 2:SUITE A
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-351-8900
Practice Address - Fax:618-351-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty