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General NPI Number Information
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NPI Number | 1497438493
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Entity Type | Individual
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Provider Name | JACKSON CHARLES GRAHAM OD
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Gender | Male
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Dates
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Enumeration Date | 08/08/2023
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Last Update Date | 07/02/2025
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Provider Practice Location Address
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Address Line | 820 STATE LINE RD
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City | WEST SILOAM SPRINGS
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State | OK
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Zip | 74338
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Country | US
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Telephone | 918-422-5811
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 460
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City | GENTRY
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State | AR
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Zip | 72734-0460
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Country | US
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Telephone | 918-931-2729
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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 | 2894
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3224
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License Number State | OK
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