Provider Demographics
NPI:1689285819
Name:JACKSON OCULOFACIAL AND COSMETIC SURGERY PA
Entity Type:Organization
Organization Name:JACKSON OCULOFACIAL AND COSMETIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-790-7628
Mailing Address - Street 1:1213 HERMANN DR STE 540
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-7089
Mailing Address - Country:US
Mailing Address - Phone:404-790-7628
Mailing Address - Fax:
Practice Address - Street 1:3636 GREENBRIAR DR STE 2A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098-4004
Practice Address - Country:US
Practice Address - Phone:832-899-5699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Single Specialty