Provider Demographics
NPI:1124366497
Name:JACKSON, CHRIS G (COTA)
Entity Type:Individual
Prefix:MR
First Name:CHRIS
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 COLUMBUS
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-5512
Mailing Address - Country:US
Mailing Address - Phone:682-365-2442
Mailing Address - Fax:
Practice Address - Street 1:6191 N STATE HIGHWAY 161 STE 650
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2250
Practice Address - Country:US
Practice Address - Phone:972-812-3299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209724172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker