Provider Demographics
NPI:1760485106
Name:JACKSON, JULIE ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:ANN
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 1:11927 COBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-5053
Mailing Address - Country:US
Mailing Address - Phone:713-668-8890
Mailing Address - Fax:713-668-8890
Practice Address - Street 1:11927 COBBLESTONE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-5053
Practice Address - Country:US
Practice Address - Phone:713-668-8890
Practice Address - Fax:713-668-8890
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5394TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041991301Medicaid
TX041991301Medicaid
TX83340EMedicare ID - Type Unspecified