Individual
DR. JACKSON ROMAINE BENNETT JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
4530 N BRANDYWINE DR, EYEGLASS WORLD 12, PEORIA, IL 61614-5570
(309) 682-5833
(309) 682-5929
Mailing address
4530 N BRANDYWINE DR, EYEGLASS WORLD 12, PEORIA, IL 61614-5570
(309) 682-5833
(309) 682-5929
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0040030668
BCBS PROVIDER #
IL
01
—
0040030672
BCBS PROVIDER #
IL
01
—
0040030676
BCBS PROVIDER #
IL
Enumeration date
01/14/2007
Last updated
07/08/2007
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