Provider Demographics
NPI:1780161984
Name:JACKSON, TIFFANI (OD)
Entity type:Individual
Prefix:
First Name:TIFFANI
Middle Name:
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:HIGHWAY JUNCTION 57, ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY JUNCTION 57, ROUTE 9
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313
Practice Address - Country:US
Practice Address - Phone:505-786-2593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist