Provider Demographics
NPI:1235534207
Name:JACKSON FAMILY EYE CARE, LLC
Entity Type:Organization
Organization Name:JACKSON FAMILY EYE CARE, LLC
Other - Org Name:JACKSON EYE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-689-6722
Mailing Address - Street 1:5370 CAMPBELLTON FAIRBURN RD
Mailing Address - Street 2:410
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-2296
Mailing Address - Country:US
Mailing Address - Phone:972-689-6722
Mailing Address - Fax:
Practice Address - Street 1:5370 CAMPBELLTON FAIRBURN RD
Practice Address - Street 2:410
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-2296
Practice Address - Country:US
Practice Address - Phone:972-689-6722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty