Provider Demographics
NPI:1851566467
Name:JACKSON, DAVID KENNETH (ABOC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:KENNETH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 ELDERON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4802
Mailing Address - Country:US
Mailing Address - Phone:410-664-4508
Mailing Address - Fax:410-664-0605
Practice Address - Street 1:4200 ELDERON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4802
Practice Address - Country:US
Practice Address - Phone:410-664-4508
Practice Address - Fax:410-664-0605
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD072195156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician