Healthcare Provider Details

I. General information

NPI: 1003125535
Provider Name (Legal Business Name): CHILDERS AND JACKSON FAMILY EYE CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 FALLS BLVD S STE A
WYNNE AR
72396-3508
US

IV. Provider business mailing address

723 FALLS BLVD S STE A
WYNNE AR
72396-3508
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-9407
  • Fax: 870-238-4320
Mailing address:
  • Phone: 870-238-9407
  • Fax: 870-238-4320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JULIA RM JACKSON
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 870-238-9407