Provider Demographics
NPI:1649352691
Name:JACKSON, JOSEPH BARRY (OD)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:BARRY
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 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9542
Practice Address - Street 1:3323 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1101
Practice Address - Country:US
Practice Address - Phone:815-220-0652
Practice Address - Fax:815-220-0732
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46007341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCG4165OtherMEDICARE RAILROAD
IL7215175OtherBLUE CROSS BLUE SHIELD
IL7215175OtherBLUE CROSS BLUE SHIELD