Provider Demographics
NPI:1366435471
Name:JACKSON, ANGELA KATHRYN (OD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:KATHRYN
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 1:27530 SWARTZWALDER RD
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43447-9426
Mailing Address - Country:US
Mailing Address - Phone:419-836-8755
Mailing Address - Fax:419-666-9605
Practice Address - Street 1:647 LIME CITY RD
Practice Address - Street 2:
Practice Address - City:ROSSFORD
Practice Address - State:OH
Practice Address - Zip Code:43460-1444
Practice Address - Country:US
Practice Address - Phone:419-666-0700
Practice Address - Fax:419-666-9605
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4846152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03158OtherPARAMOUNT
ND000000185975OtherANTHEM
OH5850518OtherAETNA
OH2051416Medicaid
OH03158OtherPARAMOUNT
OH0836037Medicare ID - Type Unspecified