Provider Demographics
NPI:1205037322
Name:JACKSON, ANTONIOUS DEWAYNE (DC, FNP-C)
Entity Type:Individual
Prefix:
First Name:ANTONIOUS
Middle Name:DEWAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC, 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:PO BOX 627
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-0627
Mailing Address - Country:US
Mailing Address - Phone:817-770-3565
Mailing Address - Fax:817-921-3001
Practice Address - Street 1:2900 HIGHWAY 121 STE 120
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4033
Practice Address - Country:US
Practice Address - Phone:817-921-3000
Practice Address - Fax:817-921-3001
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC9074111NR0400X
TXAP133741363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111NR0400XChiropractic ProvidersChiropractorRehabilitation