Provider Demographics
NPI:1922008663
Name:JACKSON, RUSSELL B (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:B
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:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:UT
Mailing Address - Zip Code:84631-0073
Mailing Address - Country:US
Mailing Address - Phone:435-743-6572
Mailing Address - Fax:435-743-5558
Practice Address - Street 1:210 S 100 E
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:UT
Practice Address - Zip Code:84631-2500
Practice Address - Country:US
Practice Address - Phone:435-743-6572
Practice Address - Fax:435-743-5558
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375344-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT37534499300001OtherBLUE CROSS
UT37534499300001OtherBLUE CROSS
UT000057350Medicare PIN