Provider Demographics
NPI:1326001041
Name:ELSON, JACKIE L (PA)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:L
Last Name:ELSON
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:16980 DALLAS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1908
Mailing Address - Country:US
Mailing Address - Phone:817-461-8327
Mailing Address - Fax:817-275-2525
Practice Address - Street 1:902 W RANDOL MILL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2572
Practice Address - Country:US
Practice Address - Phone:817-461-8327
Practice Address - Fax:817-275-2525
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA01090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189128501Medicaid
TX189128501Medicaid
TX85N264Medicare PIN