Provider Demographics
NPI:1083148373
Name:JACKSON, ROBERT SR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-2550
Mailing Address - Country:US
Mailing Address - Phone:817-846-9926
Mailing Address - Fax:817-386-5445
Practice Address - Street 1:150 S BEACH ST # A
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-1162
Practice Address - Country:US
Practice Address - Phone:817-846-9926
Practice Address - Fax:817-386-5445
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist