Provider Demographics
NPI:1164297115
Name:VICKERSON, JOHNATHAN (LDO)
Entity Type:Individual
Prefix:MR
First Name:JOHNATHAN
Middle Name:
Last Name:VICKERSON
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7325 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2950
Mailing Address - Country:US
Mailing Address - Phone:404-583-5162
Mailing Address - Fax:678-422-0759
Practice Address - Street 1:7325 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2950
Practice Address - Country:US
Practice Address - Phone:404-583-5162
Practice Address - Fax:678-422-0759
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
002489156FC0800X
171400000X
GA002489156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
No171400000XOther Service ProvidersHealth & Wellness Coach