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General NPI Number Information
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NPI Number | 1235534207
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Entity Type | Organization
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Legal Business Name | JACKSON FAMILY EYE CARE, LLC
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Dates
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Enumeration Date | 11/03/2014
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Last Update Date | 03/27/2015
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Provider Practice Location Address
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Address Line | 5370 CAMPBELLTON FAIRBURN RD 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 | 972-689-6722
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Fax |
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Provider Business Mailing Address
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Address Line | 5370 CAMPBELLTON FAIRBURN RD 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 | 972-689-6722
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Fax |
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Authorized Official
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Title or Position | OWNER/ OPTOMETRIST
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Name | DR. DANIELLE NICOLE JACKSON
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Credential | OD
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Telephone | 972-689-6722
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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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