Provider Demographics
NPI:1063494797
Name:CHEN, JACKSON C (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:C
Last Name:CHEN
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 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0995
Practice Address - Street 1:14725 COMPASS ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78418-6030
Practice Address - Country:US
Practice Address - Phone:361-949-6290
Practice Address - Fax:361-949-6268
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5082207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363090YLPSOtherWELLMED PTAN
TX142694204Medicaid
G70249Medicare UPIN
TX142694204Medicaid
TX363090YMJMMedicare PIN
TX363090YMJMMedicare PIN