Provider Demographics
NPI:1093744989
Name:JACK H. HENRY MD PA
Entity Type:Organization
Organization Name:JACK H. HENRY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR, MANAGED CARE
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:P
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-785-7676
Mailing Address - Street 1:PO BOX 16585
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79490-6585
Mailing Address - Country:US
Mailing Address - Phone:806-785-2045
Mailing Address - Fax:806-785-0872
Practice Address - Street 1:4004 82ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1900
Practice Address - Country:US
Practice Address - Phone:806-792-5500
Practice Address - Fax:806-722-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD1880207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C16823Medicare UPIN
8C8048Medicare ID - Type Unspecified