Provider Demographics
NPI:1437140779
Name:JACKSON, JOHN S (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6445 HARRIS PKWY
Mailing Address - Street 2:STE. 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4138
Mailing Address - Country:US
Mailing Address - Phone:817-361-6900
Mailing Address - Fax:817-263-2918
Practice Address - Street 1:6445 HARRIS PKWY
Practice Address - Street 2:STE. 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4138
Practice Address - Country:US
Practice Address - Phone:817-361-6900
Practice Address - Fax:817-263-2918
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1626207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
85Y011OtherBCBS
4035105OtherAETNA
4035105OtherAETNA
D66614Medicare UPIN