Healthcare Provider Details

I. General information

NPI: 1780161984
Provider Name (Legal Business Name): TIFFANI JACKSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY JUNCTION 57, ROUTE 9
CROWNPOINT NM
87313
US

IV. Provider business mailing address

HIGHWAY JUNCTION 57, ROUTE 9
CROWNPOINT NM
87313
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-2593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0003415
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: