Provider Demographics
NPI:1972502391
Name:JACKSON, DANIEL MARK (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
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 1:713 N 114TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-1515
Mailing Address - Country:US
Mailing Address - Phone:402-991-3131
Mailing Address - Fax:
Practice Address - Street 1:713 N 114TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-1515
Practice Address - Country:US
Practice Address - Phone:402-991-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE960152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE37154OtherBCBS
NE10025388500Medicaid
NEP00393695OtherRR MEDICARE
NE904415OtherSHARE ADVANTAGE
NE10025583800Medicaid
NE10025388400Medicaid
NE4589570001Medicare NSC
NE37154OtherBCBS
NEP00393695OtherRR MEDICARE