Provider Demographics
NPI:1518042233
Name:JACKSON, ERIC A (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 SIXTH STREET, SUITE #210
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301
Mailing Address - Country:US
Mailing Address - Phone:940-761-6004
Mailing Address - Fax:
Practice Address - Street 1:811 SIXTH STREET, SUITE #210
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301
Practice Address - Country:US
Practice Address - Phone:940-761-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2018-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTPA00011207P00000X
OHDO TRAINING CERT.207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS192110801Medicaid
PENDINGMedicare ID - Type Unspecified
MS192110801Medicaid