Provider Demographics
NPI:1710046610
Name:TACK, JEFFREY S (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:TACK
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 1:820 OCEAN BEACH HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4080
Mailing Address - Country:US
Mailing Address - Phone:360-636-2020
Mailing Address - Fax:360-425-0221
Practice Address - Street 1:820 OCEAN BEACH HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4011
Practice Address - Country:US
Practice Address - Phone:360-636-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00002037152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA410024013OtherRAIL ROAD MEDICARE
WA2013696Medicaid
WA50D2022229OtherCLIA#
WA410024013OtherRAIL ROAD MEDICARE
WA50D2022229OtherCLIA#