Provider Demographics
NPI:1659388114
Name:JACKSON, CLAUDINE JACQUELINE (OD)
Entity Type:Individual
Prefix:
First Name:CLAUDINE
Middle Name:JACQUELINE
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 1:6 E EPPLEY DR
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-4378
Mailing Address - Country:US
Mailing Address - Phone:717-240-0311
Mailing Address - Fax:
Practice Address - Street 1:4920 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2604
Practice Address - Country:US
Practice Address - Phone:218-522-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPOP64152W00000X
WI3861-35152W00000X
MN3690152W00000X
NY009081152W00000X
PAOET008991152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist