Provider Demographics
NPI:1275649444
Name:JACKSON CONDON, KELLEY R (OD)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:R
Last Name:JACKSON CONDON
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 1:1409 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401
Mailing Address - Country:US
Mailing Address - Phone:303-271-1400
Mailing Address - Fax:303-271-9314
Practice Address - Street 1:1409 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401
Practice Address - Country:US
Practice Address - Phone:303-271-1400
Practice Address - Fax:303-271-9314
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1678152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08016784Medicaid
CO75473Medicare ID - Type Unspecified
CO08016784Medicaid