Provider Demographics
NPI:1780023234
Name:JACKSON, JESSICA M (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:HARTWIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2822 VENTURE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-228-4401
Mailing Address - Fax:906-225-0460
Practice Address - Street 1:2822 VENTURE DRIVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-228-4401
Practice Address - Fax:906-225-0460
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004770152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP1657004Medicare PIN