Provider Demographics
NPI:1346485927
Name:CHERYL JACKSON OD PC
Entity Type:Organization
Organization Name:CHERYL JACKSON OD PC
Other - Org Name:CHERYL JACKSON OD PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, OD
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-234-7055
Mailing Address - Street 1:10 EAST SCRANTON AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044
Mailing Address - Country:US
Mailing Address - Phone:847-234-7055
Mailing Address - Fax:
Practice Address - Street 1:10 E. SCRANTON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044
Practice Address - Country:US
Practice Address - Phone:847-234-7055
Practice Address - Fax:847-234-7166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36153Medicare UPIN
IL597330Medicare PIN