Provider Demographics
NPI:1457657371
Name:PHYSICIAN SERVICES OF JACKSBORO PA
Entity Type:Organization
Organization Name:PHYSICIAN SERVICES OF JACKSBORO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-565-0922
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034
Mailing Address - Country:US
Mailing Address - Phone:817-565-0922
Mailing Address - Fax:
Practice Address - Street 1:709 N 4TH ST
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TX
Practice Address - Zip Code:76458-1132
Practice Address - Country:US
Practice Address - Phone:817-565-0922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0036XBOtherBCBS