Provider Demographics
NPI:1174053433
Name:JACKSON, ALYSSA (OD)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
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 1:3929 LAMAR DR STE. B
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-1425
Mailing Address - Country:US
Mailing Address - Phone:931-245-3937
Mailing Address - Fax:931-647-0354
Practice Address - Street 1:3929 LAMAR DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3704
Practice Address - Country:US
Practice Address - Phone:931-245-3979
Practice Address - Fax:931-647-0354
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3377152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3377OtherLICENSE NUMBER