Provider Demographics
NPI:1609807015
Name:JACKSON, FREDRICK J (OD)
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:J
Last Name:JACKSON
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 1:8436 VAUGHN RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-8862
Mailing Address - Country:US
Mailing Address - Phone:334-271-3900
Mailing Address - Fax:334-271-3915
Practice Address - Street 1:8436 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-8862
Practice Address - Country:US
Practice Address - Phone:334-271-3900
Practice Address - Fax:334-271-3915
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS553TA209152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL008605730Medicaid
ALBC51059948OtherAL51059948
ALBC51059948OtherAL51059948
AL008605730Medicaid