Provider Demographics
NPI:1275682403
Name:JACKSON, JAMES PAUL (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:PAUL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5035
Mailing Address - Country:US
Mailing Address - Phone:970-259-1789
Mailing Address - Fax:970-259-0810
Practice Address - Street 1:1845 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5035
Practice Address - Country:US
Practice Address - Phone:970-259-1789
Practice Address - Fax:970-259-0810
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18555306Medicaid
COU06091Medicare UPIN
CO18555306Medicaid