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General NPI Number Information
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NPI Number | 1497071625
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Entity Type | Organization
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Legal Business Name | DR. M.E. JACKSON OPTOMETRIST PC
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Dates
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Enumeration Date | 04/13/2010
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Last Update Date | 04/13/2010
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Provider Practice Location Address
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Address Line | 4642 HAYGOOD RD SUITE 1
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-5436
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Country | US
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Telephone | 757-464-5842
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Fax | 757-464-4745
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Provider Business Mailing Address
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Address Line | 4642 HAYGOOD RD SUITE 1
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-5436
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Country | US
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Telephone | 757-464-5842
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Fax | 757-464-4745
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Authorized Official
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Title or Position | DOCTOR/ SOLE OWNER
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Name | DR. MELVIN EUGENE JACKSON
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Credential | O.D.
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Telephone | 757-464-5842
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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 | 0618000174
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License Number State | VA
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