Organization
KELLI JACKSON
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KELLI J JACKSON OD (OPTOMETRIST)
(252) 985-1371
Entity
Organization
Contact information
Practice address
114 STUART RD NE, #102, CLEVELAND, TN 37312-4803
(252) 985-1371
Mailing address
PO BOX 7396, ROCKY MOUNT, NC 27804-0396
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1566
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3940088
—
TN
01
—
4134928
BCBS PROVIDER NUMBER
TN
01
—
P00265658
RAILROAD MEDICARE
TN
Enumeration date
03/20/2007
Last updated
07/03/2008
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