Provider Demographics
NPI:1407013691
Name:JACKSON, SHAUN CHADRICK (MD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:CHADRICK
Last Name:JACKSON
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 1:45 NE LOOP 410 STE 850
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5824
Mailing Address - Country:US
Mailing Address - Phone:210-805-9800
Mailing Address - Fax:210-805-8770
Practice Address - Street 1:423 TREELINE PARK
Practice Address - Street 2:SUITE 325
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-2060
Practice Address - Country:US
Practice Address - Phone:210-805-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9372208100000X, 2081P2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM9372OtherMEDICAL LICENSE
TX8L0027OtherMEDICARE PTAN
TX1984007-01Medicaid