Healthcare Provider Details

I. General information

NPI: 1457377418
Provider Name (Legal Business Name): JACKSON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5620 A CRAWFORDSVILLE RD
SPEEDWAY IN
46224
US

IV. Provider business mailing address

10775 NORTHHAMPTON DRIVE
FISHERS IN
46038
US

V. Phone/Fax

Practice location:
  • Phone: 317-243-5423
  • Fax: 217-243-5424
Mailing address:
  • Phone: 317-577-9897
  • Fax: 317-577-9897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ALISSA D JACKSON
Title or Position: OPTOMETRIST
Credential: OD
Phone: 317-577-9897