Provider Demographics
NPI:1023015005
Name:JACKSON, MARK D (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:JACKSON
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 1:1250 E MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-2702
Mailing Address - Country:US
Mailing Address - Phone:970-224-0606
Mailing Address - Fax:970-493-9309
Practice Address - Street 1:1250 E MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2702
Practice Address - Country:US
Practice Address - Phone:970-224-0606
Practice Address - Fax:970-493-9309
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2023-05-15
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
CO2187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU65211Medicare UPIN
COC486678Medicare PIN