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General NPI Number Information
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NPI Number | 1720574544
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Entity Type | Individual
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Provider Name | DEVIN JACKSON
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Gender | Male
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Dates
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Enumeration Date | 07/04/2018
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Last Update Date | 10/17/2019
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Provider Practice Location Address
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Address Line | 3958 N ACADEMY BLVD STE 108
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City | COLORADO SPRINGS
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State | CO
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Zip | 80917-5911
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Country | US
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Telephone | 719-999-8404
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Fax | 719-999-8402
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Provider Business Mailing Address
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Address Line | 3425 AUSTIN BLUFFS PKWY STE 108
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City | COLORADO SPRINGS
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State | CO
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Zip | 80918-5723
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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 | 0003396
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License Number State | CO
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