Provider Demographics
NPI:1043480007
Name:JACKSON, RICHARD (MD0416)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD0416
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 4TH ST
Mailing Address - Street 2:MS 8103
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-0002
Mailing Address - Country:US
Mailing Address - Phone:806-743-2800
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:MS 8103
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program