Provider Demographics
NPI:1477739100
Name:JACKSON, AUTUMN H (OD)
Entity Type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:H
Last Name:JACKSON
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 1:73 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-5234
Mailing Address - Country:US
Mailing Address - Phone:401-847-1040
Mailing Address - Fax:401-847-1049
Practice Address - Street 1:73 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5234
Practice Address - Country:US
Practice Address - Phone:401-847-1040
Practice Address - Fax:401-847-1049
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4642152W00000X
RIODTA00538152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0718769Medicaid
RIAJ73813Medicaid
MA0718769Medicaid
MA000639301Medicare PIN
MA000697901Medicare PIN