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General NPI Number Information
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NPI Number | 1043568413
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Entity Type | Individual
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Provider Name | DANIELLE NICOLE JACKSON O.D.
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Gender | Female
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Dates
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Enumeration Date | 08/16/2012
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Last Update Date | 12/15/2016
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Provider Practice Location Address
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Address Line | 3360 SHELBY LN SUITE 1010
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City | EAST POINT
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State | GA
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Zip | 30344-5744
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Country | US
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Telephone | 404-344-0274
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Fax | 404-344-4581
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Provider Business Mailing Address
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Address Line | 5370 HIGHWAY 92 STE 410
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City | FAIRBURN
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State | GA
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Zip | 30213-2296
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Country | US
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Telephone | 770-629-4351
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Fax | 770-703-3398
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | OPT002717
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License Number State | GA
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