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General NPI Number Information
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NPI Number | 1831316090
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Entity Type | Organization
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Legal Business Name | MARK D. JACKSON, OD AND ASSOC., PC
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1325 N DENVER AVE
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City | LOVELAND
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State | CO
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Zip | 80537
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Country | US
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Telephone | 970-224-0606
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Fax |
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Provider Business Mailing Address
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Address Line | 1250 EAST MAGNOLIA STREET
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City | FORT COLLINS
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State | CO
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Zip | 80526
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Country | US
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Telephone | 970-224-0606
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Fax |
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Authorized Official
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Title or Position | PRES
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Name | DR. MARK D JACKSON
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Credential | OD
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Telephone | 970-224-0606
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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 | 2187
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License Number State | CO
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