Healthcare Provider Details

I. General information

NPI: 1588654115
Provider Name (Legal Business Name): KEVIN MICHAEL JACKSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 PALMER RD N
BETHESDA MD
20814
US

IV. Provider business mailing address

4301 JONES BRIDGE RD
BETHESDA MD
20814-4712
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-3016
  • Fax:
Mailing address:
  • Phone: 301-295-3016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT006010
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: