Provider Demographics
NPI:1215121140
Name:JACKSON VISION CLINIC INC
Entity type:Organization
Organization Name:JACKSON VISION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-395-2266
Mailing Address - Street 1:3324 RAINIER AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-6034
Mailing Address - Country:US
Mailing Address - Phone:206-322-6915
Mailing Address - Fax:206-395-2315
Practice Address - Street 1:3324 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-6034
Practice Address - Country:US
Practice Address - Phone:206-322-6915
Practice Address - Fax:206-395-2315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD3718152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2026425Medicaid
WA2026425Medicaid