Provider Demographics
NPI:1427116888
Name:JACKS, DANIEL LEROY (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LEROY
Last Name:JACKS
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 1:7903 W GRANDRIDGE BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7827
Mailing Address - Country:US
Mailing Address - Phone:509-783-0667
Mailing Address - Fax:509-735-7981
Practice Address - Street 1:7903 W GRANDRIDGE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7827
Practice Address - Country:US
Practice Address - Phone:509-783-0667
Practice Address - Fax:509-735-7981
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1091152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2040707Medicaid
WAT02327Medicare UPIN
WAAB38235Medicare ID - Type Unspecified