Provider Demographics
NPI:1831174275
Name:JACKSON, WAYNE STEWART (OD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:STEWART
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 1:4613 DOUG DR
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-9647
Mailing Address - Country:US
Mailing Address - Phone:231-894-9893
Mailing Address - Fax:
Practice Address - Street 1:4613 DOUG DR
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-9647
Practice Address - Country:US
Practice Address - Phone:231-894-9893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002699152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0182710001Medicare NSC
T33314Medicare UPIN