1922150663 NPI number — J. DON JACKSON JR, MD, PA

Table of content: (NPI 1922150663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922150663 NPI number — J. DON JACKSON JR, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J. DON JACKSON JR, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922150663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 817
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALESTINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-723-8210
Provider Business Mailing Address Fax Number:
903-723-8310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 WILLOW CREEK PKWY
Provider Second Line Business Practice Location Address:
SUITE 200 A
Provider Business Practice Location Address City Name:
PALESTINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75801-4421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-723-8210
Provider Business Practice Location Address Fax Number:
903-723-8310
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
DON
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
903-723-8210

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 178962001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com