Provider Demographics
NPI:1104975838
Name:JACKSON, JAY A (OD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MONASTERY RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31411-1737
Mailing Address - Country:US
Mailing Address - Phone:912-398-0418
Mailing Address - Fax:
Practice Address - Street 1:5500 ABERCORN ST
Practice Address - Street 2:12 OAKS PLAZA SUITE 24
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6913
Practice Address - Country:US
Practice Address - Phone:912-352-3478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCCKZMedicare ID - Type Unspecified
GAU5918Medicare UPIN