Provider Demographics
NPI:1780772533
Name:JACKSON, CHAD J (OD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:J
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 1:6575 BELDING RD NE STE D
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7417
Mailing Address - Country:US
Mailing Address - Phone:616-874-2020
Mailing Address - Fax:616-874-2773
Practice Address - Street 1:6575 BELDING RD NE
Practice Address - Street 2:SUITE D
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7418
Practice Address - Country:US
Practice Address - Phone:616-874-2020
Practice Address - Fax:616-874-2773
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003954152WC0802X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI90OD114940OtherBLUECROSS/BLUE SHEILD
MIU72928Medicare UPIN
MIP23650001Medicare PIN