MEDICARE: DEBRY JACKSON OPHTHALMOLOGY PLLC

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	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1366992141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEBRY JACKSON OPHTHALMOLOGY PLLC

Provider Business Mailing Address
First Line	:	2850 W HORIZON RIDGE PKWY STE 300
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-4395
Country	:	US
Telephone Number	:	702-202-4776
Fax Number	:	702-852-5743

Provider Business Practice Location Address
First Line	:	2390 W HORIZON RIDGE PKWY
Second Line	:	SUITE 100
City	:	HENDERSON
State	:	NV
Zip	:	89052-5079
Country	:	US
Telephone Number	:	702-825-2085
Fax Number	:	702-852-5743

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	AMY GRIM
Credential	:
Telephone Number	:	702-202-4776

Provider Enumeration Date	:	10/05/2016
Last Update Date	:	01/17/2022

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