Provider Demographics
NPI:1770893976
Name:ACKLEY, JONATHAN P (LO)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:ACKLEY
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4270 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2306
Mailing Address - Country:US
Mailing Address - Phone:203-372-4569
Mailing Address - Fax:203-372-6550
Practice Address - Street 1:4270 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-2306
Practice Address - Country:US
Practice Address - Phone:203-372-4569
Practice Address - Fax:203-372-6550
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT783156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician