Provider Demographics
NPI:1497071625
Name:DR. M.E. JACKSON OPTOMETRIST PC
Entity Type:Organization
Organization Name:DR. M.E. JACKSON OPTOMETRIST PC
Other - Org Name:DR. M.E. JACKSON O.D., P.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR/ SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-464-5842
Mailing Address - Street 1:4642 HAYGOOD RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5436
Mailing Address - Country:US
Mailing Address - Phone:757-464-5842
Mailing Address - Fax:757-464-4745
Practice Address - Street 1:4642 HAYGOOD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5436
Practice Address - Country:US
Practice Address - Phone:757-464-5842
Practice Address - Fax:757-464-4745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1588657217OtherNPI
VA0092-0598-5Medicaid
VA040971OtherBLUE CROSS & BLUE SHIELD
VA0389100001Medicare NSC
VA040971OtherBLUE CROSS & BLUE SHIELD
T21621Medicare UPIN