Provider Demographics
NPI:1407301997
Name:JACKSON, BOBBY (L AC)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-4322
Mailing Address - Country:US
Mailing Address - Phone:512-341-9900
Mailing Address - Fax:
Practice Address - Street 1:894 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-4322
Practice Address - Country:US
Practice Address - Phone:512-341-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00650171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist