Provider Demographics
NPI:1053467902
Name:JACKSON, MICHAEL RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N FIRST ST
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-3033
Mailing Address - Country:US
Mailing Address - Phone:972-771-5366
Mailing Address - Fax:972-771-0424
Practice Address - Street 1:103 N FIRST ST
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-3033
Practice Address - Country:US
Practice Address - Phone:972-771-5366
Practice Address - Fax:972-771-0424
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19730207Q00000X
TXN0853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine