Provider Demographics
NPI:1831316090
Name:MARK D. JACKSON, OD AND ASSOC., PC
Entity Type:Organization
Organization Name:MARK D. JACKSON, OD AND ASSOC., PC
Other - Org Name:JACKSON EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-224-0606
Mailing Address - Street 1:1250 EAST MAGNOLIA STREET
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526
Mailing Address - Country:US
Mailing Address - Phone:970-224-0606
Mailing Address - Fax:
Practice Address - Street 1:1325 N DENVER AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537
Practice Address - Country:US
Practice Address - Phone:970-224-0606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU65211Medicare UPIN
CO486668Medicare ID - Type UnspecifiedGROUP