Provider Demographics
NPI:1720347644
Name:JACKSON, TRICHELLE MAE (OD)
Entity Type:Individual
Prefix:
First Name:TRICHELLE
Middle Name:MAE
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:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50436-0410
Mailing Address - Country:US
Mailing Address - Phone:641-585-3590
Mailing Address - Fax:641-585-4058
Practice Address - Street 1:139 E K ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:IA
Practice Address - Zip Code:50436-1501
Practice Address - Country:US
Practice Address - Phone:641-585-3590
Practice Address - Fax:641-585-4058
Is Sole Proprietor?:No
Enumeration Date:2012-05-12
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002543152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
I75220001Medicare PIN
IB2519002Medicare PIN
I75190001Medicare PIN