Healthcare Provider Details

I. General information

NPI: 1073180741
Provider Name (Legal Business Name): WALTER LEE JACKSON II OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 WARM SPRINGS ROAD
COLUMBUS GA
31904-5323
US

IV. Provider business mailing address

PO BOX 11407
BIRMINGHAM AL
35246-8575
US

V. Phone/Fax

Practice location:
  • Phone: 706-507-7530
  • Fax: 706-221-9797
Mailing address:
  • Phone: 864-359-1308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003364
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-E78
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-E78-TA-C17
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberS-E78-TA-C17
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberS-E78
License Number StateAL
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberS-E78
License Number StateAL
# 7
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberS-E78-TA-C17
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: