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General NPI Number Information
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NPI Number | 1083266126
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Entity Type | Individual
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Provider Name | HEATHER JACKSON OD
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Gender | Female
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Dates
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Enumeration Date | 07/09/2019
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Last Update Date | 10/01/2019
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Provider Practice Location Address
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Address Line | 2070 EAGLE CREEK LN STE 200
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City | WOODBURY
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State | MN
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Zip | 55129-3217
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Country | US
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Telephone | 651-738-8040
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Fax | 651-714-0759
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Provider Business Mailing Address
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Address Line | PO BOX 171
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City | SAINT MICHAEL
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State | MN
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Zip | 55376-0171
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Country | US
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Telephone |
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Fax |
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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 | 3641
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License Number State | MN
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