Provider Demographics
NPI:1821472267
Name:GRANT, JARED ACKER (OD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:ACKER
Last Name:GRANT
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 1:5219 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-1719
Mailing Address - Country:US
Mailing Address - Phone:662-612-6016
Mailing Address - Fax:662-612-6031
Practice Address - Street 1:5219 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-1719
Practice Address - Country:US
Practice Address - Phone:662-612-6016
Practice Address - Fax:662-612-6031
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR-295-TA-C49152W00000X
VA0618003092152W00000X
WI3847-35152W00000X
MS923152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04774359Medicaid