Provider Demographics
NPI:1477540136
Name:JONES, JACKIE MICHAEL (OD)
Entity Type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:MICHAEL
Last Name:JONES
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 1:2004 W PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-1423
Mailing Address - Country:US
Mailing Address - Phone:765-284-4371
Mailing Address - Fax:
Practice Address - Street 1:3501 N GRANVILLE AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-1263
Practice Address - Country:US
Practice Address - Phone:765-289-8005
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002439B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U01326Medicare UPIN