Provider Demographics
NPI:1225042609
Name:JACKSON, DANIEL WAYNE JR (PHD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:WAYNE
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NORWOOD DR
Mailing Address - Street 2:#205
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3651
Mailing Address - Country:US
Mailing Address - Phone:817-282-1885
Mailing Address - Fax:817-282-1683
Practice Address - Street 1:1500 NORWOOD DR
Practice Address - Street 2:#205
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3651
Practice Address - Country:US
Practice Address - Phone:817-282-1885
Practice Address - Fax:817-282-1683
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22481103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00FJ26Medicare ID - Type Unspecified