Provider Demographics
NPI:1073752879
Name:JACKSON, RUSSELL BRENT (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:BRENT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 593377
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-0218
Mailing Address - Country:US
Mailing Address - Phone:210-494-9600
Mailing Address - Fax:210-494-9601
Practice Address - Street 1:155 E SONTERRA BLVD STE 111
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3988
Practice Address - Country:US
Practice Address - Phone:210-729-1900
Practice Address - Fax:210-729-1901
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5384207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery