Provider Demographics
NPI:1366445611
Name:PRESTON, JACKIE LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:LYNN
Last Name:PRESTON
Suffix:
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 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:
Practice Address - Street 1:120 E HARRIS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5904
Practice Address - Country:US
Practice Address - Phone:325-653-6741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4758207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133739610Medicaid
TX8R7522OtherBCBS
TXC20672Medicare UPIN
TX8G4644Medicare PIN
TX8R7522OtherBCBS