Provider Demographics
NPI:1962628073
Name:JACKSON, DUANE L JR (OD)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:L
Last Name:JACKSON
Suffix:JR
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 1:28815 PACIFIC HWY S STE 2
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-3876
Mailing Address - Country:US
Mailing Address - Phone:253-941-7074
Mailing Address - Fax:253-941-5079
Practice Address - Street 1:28815 PACIFIC HWY S STE 2
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-3876
Practice Address - Country:US
Practice Address - Phone:253-941-7074
Practice Address - Fax:253-941-5079
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00002039152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA120065OtherLABOR AND INDUSTRIES
WA2015139Medicaid
WAG8872671Medicare PIN
U34640Medicare UPIN