Provider Demographics
NPI:1851814396
Name:JACKSON, ALEX MITCHELL (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:MITCHELL
Last Name:JACKSON
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 1:2699 TOWNSEND CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-6487
Mailing Address - Country:US
Mailing Address - Phone:931-647-8417
Mailing Address - Fax:931-648-4435
Practice Address - Street 1:2699 TOWNSEND CT
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6487
Practice Address - Country:US
Practice Address - Phone:931-647-8417
Practice Address - Fax:931-648-4435
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3379152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ009057Medicaid