Provider Demographics
NPI:1326109661
Name:JACKSON, WILLIAM JR (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:JACKSON
Suffix:JR
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 1:1012 OAK PARK DR
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77515-7846
Mailing Address - Country:US
Mailing Address - Phone:979-549-9720
Mailing Address - Fax:
Practice Address - Street 1:4 WEST WAY COURT
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5242
Practice Address - Country:US
Practice Address - Phone:979-297-3937
Practice Address - Fax:979-297-9889
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4491TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E71SMedicare ID - Type Unspecified
TXU24852Medicare UPIN