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General NPI Number Information
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NPI Number | 1114100740
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Entity Type | Organization
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Legal Business Name | JACKSON EYE CARE, INC
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Dates
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Enumeration Date | 12/05/2007
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Last Update Date | 02/11/2008
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Provider Practice Location Address
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Address Line | 51 E 400 N SUITE 4A
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City | CEDAR CITY
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State | UT
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Zip | 84720-2686
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Country | US
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Telephone | 435-586-1500
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Fax | 435-865-0784
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Provider Business Mailing Address
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Address Line | PO BOX 1574
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City | CEDAR CITY
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State | UT
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Zip | 84721-1574
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Country | US
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Telephone | 435-586-1500
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Fax | 435-865-0784
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Authorized Official
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Title or Position | OWNER OPERATOR
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Name | DR. RUSSELL B JACKSON
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Credential | OD
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Telephone | 435-586-1500
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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 | 375344-9934
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License Number State | UT
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