Basic Information
| Provider Information | |||||||||
| NPI: | 1316098791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | JACKSON | ||||||||
| MiddleName: | ROMAINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4530 N BRANDYWINE DR | ||||||||
| Address2: | EYEGLASS WORLD 12 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616145570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096825833 | ||||||||
| FaxNumber: | 3096825929 | ||||||||
| Practice Location | |||||||||
| Address1: | 4530 N BRANDYWINE DR | ||||||||
| Address2: | EYEGLASS WORLD 12 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616145570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096825833 | ||||||||
| FaxNumber: | 3096825929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0040030668 | 01 | IL | BCBS PROVIDER # | OTHER | 0040030676 | 01 | IL | BCBS PROVIDER # | OTHER | 0040030672 | 01 | IL | BCBS PROVIDER # | OTHER |