Provider Demographics
NPI:1568627958
Name:JACKSON, JULIA REBECCA MEYER (OD)
Entity type:Individual
Prefix:DR
First Name:JULIA
Middle Name:REBECCA MEYER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 S. FALLS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-0562
Mailing Address - Country:US
Mailing Address - Phone:870-238-2020
Mailing Address - Fax:
Practice Address - Street 1:723 S. FALLS BLVD
Practice Address - Street 2:STE A
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-0562
Practice Address - Country:US
Practice Address - Phone:870-238-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2609152WC0802X, 152WL0500X, 152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175315722Medicaid
AR4T021OtherMEDICARE
AR6477243001OtherPTAN