=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912004557
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RONALD M. JACKSON, O.D. CHARTERED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2006
-----------------------------------------------------
Last Update Date | 03/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 982 N TYLER RD SUITE A
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67212-3271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-722-6452
-----------------------------------------------------
Fax | 316-722-6001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 982 N TYLER RD SUITE A
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67212-3271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-722-6452
-----------------------------------------------------
Fax | 316-722-6001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RONALD MORRIS JACKSON
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 316-722-6452
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1293-3
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0982-3
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------