Provider Demographics
NPI:1164411013
Name:JACKSON, STEPHEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605-4733
Mailing Address - Country:US
Mailing Address - Phone:866-321-8433
Mailing Address - Fax:
Practice Address - Street 1:4716 S 14TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-4733
Practice Address - Country:US
Practice Address - Phone:325-232-8668
Practice Address - Fax:325-701-9970
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4113207PE0004X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130376007Medicaid
TX8599B6Medicare ID - Type Unspecified