Provider Demographics
NPI:1215019864
Name:JACKSON, CHERYL (OD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3399
Mailing Address - Country:US
Mailing Address - Phone:815-338-0674
Mailing Address - Fax:815-338-6139
Practice Address - Street 1:233 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3399
Practice Address - Country:US
Practice Address - Phone:815-338-0674
Practice Address - Fax:815-338-6139
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008108152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008108Medicaid
IL36153Medicare UPIN
IL046008108Medicaid