Provider Demographics
NPI:1497438493
Name:GRAHAM, JACKSON CHARLES (OD)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:CHARLES
Last Name:GRAHAM
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:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:GENTRY
Mailing Address - State:AR
Mailing Address - Zip Code:72734-0460
Mailing Address - Country:US
Mailing Address - Phone:918-931-2729
Mailing Address - Fax:
Practice Address - Street 1:820 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:WEST SILOAM SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74338
Practice Address - Country:US
Practice Address - Phone:918-422-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2894152W00000X
OK3224152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist