Provider Demographics
NPI:1639361322
Name:JACKSON OPTICAL LLC
Entity Type:Organization
Organization Name:JACKSON OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-625-6602
Mailing Address - Street 1:4265 TAMIAMI TRL
Mailing Address - Street 2:SUITE G
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33980-2152
Mailing Address - Country:US
Mailing Address - Phone:941-625-6602
Mailing Address - Fax:941-625-0021
Practice Address - Street 1:4265 TAMIAMI TRL
Practice Address - Street 2:SUITE G
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-2152
Practice Address - Country:US
Practice Address - Phone:941-625-6602
Practice Address - Fax:941-625-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE702156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5488960001OtherPALMETTO