Healthcare Provider Details

I. General information

NPI: 1760113609
Provider Name (Legal Business Name): JACKSON HAWKINS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2681 ANDERSONVILLE HWY
CLINTON TN
37716-6706
US

IV. Provider business mailing address

6719 MAYNARDVILLE PIKE
KNOXVILLE TN
37918-5308
US

V. Phone/Fax

Practice location:
  • Phone: 865-457-2020
  • Fax:
Mailing address:
  • Phone: 865-922-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3742
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: