Provider Demographics
NPI:1326799610
Name:JACKSON SURGICAL CONSULTANTS P.A.
Entity Type:Organization
Organization Name:JACKSON SURGICAL CONSULTANTS P.A.
Other - Org Name:REVIVE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELUNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-800-3359
Mailing Address - Street 1:12337 JONES RD STE 427
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4951
Mailing Address - Country:US
Mailing Address - Phone:409-299-4785
Mailing Address - Fax:409-220-8348
Practice Address - Street 1:1110 S FRIENDSWOOD DR
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-5698
Practice Address - Country:US
Practice Address - Phone:409-299-4785
Practice Address - Fax:409-220-8348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-18
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty