Provider Demographics
NPI:1407864119
Name:JACKSON, LINDA SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17051 DALLAS PKWY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-7109
Mailing Address - Country:US
Mailing Address - Phone:214-370-3535
Mailing Address - Fax:214-370-0004
Practice Address - Street 1:17051 DALLAS PKWY
Practice Address - Street 2:SUITE 400
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-7109
Practice Address - Country:US
Practice Address - Phone:214-370-3535
Practice Address - Fax:214-370-0004
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02046363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209277701Medicaid
TX8Y9248OtherBCBSTX
TX8Y9248OtherBCBSTX
TX8F10131Medicare PIN
S86697Medicare UPIN