Provider Demographics
NPI:1700439528
Name:JACKSON, CODY F (OD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:F
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 1:6114 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:CO
Mailing Address - Zip Code:80465-2203
Mailing Address - Country:US
Mailing Address - Phone:303-947-1491
Mailing Address - Fax:
Practice Address - Street 1:14500 W COLFAX AVE UNIT 524
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3235
Practice Address - Country:US
Practice Address - Phone:303-271-0354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-21
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist