MEDICARE: DR. CHERYL JACKSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046008108	IL
2	152WC0802X	Corneal and Contact Management Optometrist	046008108	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215019864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHERYL JACKSON O.D.

Provider Business Mailing Address
First Line	:	233 WASHINGTON ST
Second Line	:
City	:	WOODSTOCK
State	:	IL
Zip	:	60098-3399
Country	:	US
Telephone Number	:	815-338-0674
Fax Number	:	815-338-6139

Provider Business Practice Location Address
First Line	:	233 WASHINGTON ST
Second Line	:
City	:	WOODSTOCK
State	:	IL
Zip	:	60098-3399
Country	:	US
Telephone Number	:	815-338-0674
Fax Number	:	815-338-6139

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	04/08/2015

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