Provider Demographics
NPI:1306852678
Name:JACKSON, PHILIP C JR (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:C
Last Name:JACKSON
Suffix:JR
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:1301 W 38TH ST #205
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1011
Practice Address - Country:US
Practice Address - Phone:512-324-1864
Practice Address - Fax:512-419-9016
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7426208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159860904Medicaid
TX159860901Medicaid
TX159860902Medicaid
TX159860903Medicaid
TX159860903Medicaid
TXP00051418Medicare PIN
TX159860902Medicaid
TXTXB154850Medicare PIN
TX8K7744Medicare PIN
TX159860901Medicaid