Healthcare Provider Details

I. General information

NPI: 1497438493
Provider Name (Legal Business Name): JACKSON CHARLES GRAHAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 07/02/2025
Certification Date: 06/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 STATE LINE RD
WEST SILOAM SPRINGS OK
74338
US

IV. Provider business mailing address

PO BOX 460
GENTRY AR
72734-0460
US

V. Phone/Fax

Practice location:
  • Phone: 918-422-5811
  • Fax:
Mailing address:
  • Phone: 918-931-2729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2894
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3224
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: