=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659388114
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLAUDINE JACQUELINE JACKSON O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4920 GRAND AVE
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55807-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-522-4412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 E EPPLEY DR
-----------------------------------------------------
City | CARLISLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17013-4378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-240-0311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TPOP64
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3861-35
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3690
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 009081
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OET008991
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------