Provider Demographics
NPI:1205819638
Name:JACKSON, REBECCA KATHERINE PITT (OD)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:KATHERINE PITT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:KATHERINE
Other - Last Name:PITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2510 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7546
Mailing Address - Country:US
Mailing Address - Phone:406-531-0271
Mailing Address - Fax:
Practice Address - Street 1:2510 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7546
Practice Address - Country:US
Practice Address - Phone:406-251-4579
Practice Address - Fax:406-251-3285
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT716152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U90919Medicare UPIN