Provider Demographics
NPI:1114076882
Name:JACKSON, ROBERT ALAN (RN, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ALAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4707 TEAKWOOD TRCE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-1636
Mailing Address - Country:US
Mailing Address - Phone:432-522-1567
Mailing Address - Fax:
Practice Address - Street 1:120 E BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5919
Practice Address - Country:US
Practice Address - Phone:325-481-2247
Practice Address - Fax:325-481-2307
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX655208363LF0000X
TXAP112515363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
8C2091 00039FMedicare ID - Type Unspecified
TXQ04996Medicare UPIN