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General NPI Number Information
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NPI Number | 1407906084
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Entity Type | Individual
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Provider Name | JONATHAN FLOYD JACKSON O.D.
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Gender | Male
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5135 CAROLINA BEACH RD
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City | WILMINGTON
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State | NC
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Zip | 28412-2516
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Country | US
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Telephone | 910-793-1157
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Fax | 910-793-1158
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Provider Business Mailing Address
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Address Line | 5443 MARINA CLUB DR
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City | WILMINGTON
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State | NC
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Zip | 28409-4104
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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 | 1907
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License Number State | NC
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