Healthcare Provider Details

I. General information

NPI: 1962498634
Provider Name (Legal Business Name): A JACKSON BAILES OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 MULBERRY HEIGHTS RD
POMEROY OH
45769-9573
US

IV. Provider business mailing address

507 MULBERRY HEIGHTS RD POMEROY
POMEROY OH
45769-9573
US

V. Phone/Fax

Practice location:
  • Phone: 740-992-3279
  • Fax: 740-992-6740
Mailing address:
  • Phone: 740-992-3279
  • Fax: 740-992-6740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3385T891
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: