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General NPI Number Information
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NPI Number | 1043349467
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Entity Type | Organization
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Legal Business Name | JACKSON VISION LLC
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Dates
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Enumeration Date | 03/02/2007
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Last Update Date | 04/16/2014
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Provider Practice Location Address
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Address Line | 817 W GANSON ST
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City | JACKSON
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State | MI
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Zip | 49202-4255
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Country | US
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Telephone | 517-782-4300
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Fax | 517-782-4708
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Provider Business Mailing Address
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Address Line | 817 W GANSON ST
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City | JACKSON
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State | MI
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Zip | 49202-4255
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Country | US
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Telephone | 517-782-4300
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Fax | 517-782-4708
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. STEVEN G JOHNSON
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Credential | O.D.
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Telephone | 517-782-4300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901003631
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License Number State | MI
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