Provider Demographics
NPI:1346701133
Name:JACKSON, HILLARY MATOR (DO)
Entity Type:Individual
Prefix:
First Name:HILLARY
Middle Name:MATOR
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HILLARY
Other - Middle Name:MATOR
Other - Last Name:ADEWALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:6317 SAN MARINO DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-4534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7031 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4701
Practice Address - Country:US
Practice Address - Phone:305-284-7761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU9276208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice