Provider Demographics
NPI:1093279572
Name:JACKSON, ANDREW JAY
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAY
Last Name:JACKSON
Suffix:
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 1:125 COUNTY ROAD 4209
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-5574
Mailing Address - Country:US
Mailing Address - Phone:903-284-1056
Mailing Address - Fax:
Practice Address - Street 1:125 COUNTY ROAD 4209
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-5574
Practice Address - Country:US
Practice Address - Phone:903-284-1056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant