Provider Demographics
NPI:1194883017
Name:DRS JACKSON & LEE, INC
Entity type:Organization
Organization Name:DRS JACKSON & LEE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:253-941-7074
Mailing Address - Street 1:28815 PACIFIC HWY S
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-3906
Mailing Address - Country:US
Mailing Address - Phone:253-941-7074
Mailing Address - Fax:253-941-5079
Practice Address - Street 1:28815 PACIFIC HWY S
Practice Address - Street 2:SUITE 2
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-3906
Practice Address - Country:US
Practice Address - Phone:253-941-7074
Practice Address - Fax:253-941-5079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00002039152W00000X
WAOD00002095152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2032688Medicaid
WA2032688Medicaid