Provider Demographics
NPI:1184871626
Name:JACKSON, ERIN ATWATER (OD)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:ATWATER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 SEMORA RD
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-5185
Mailing Address - Country:US
Mailing Address - Phone:336-599-0246
Mailing Address - Fax:336-597-3356
Practice Address - Street 1:415 SEMORA RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-5185
Practice Address - Country:US
Practice Address - Phone:336-599-0246
Practice Address - Fax:336-597-3356
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2114152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910510Medicaid
NC5910510Medicaid