Provider Demographics
NPI:1528001237
Name:JACKSON, JAMES M (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WINSTED LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-3852
Mailing Address - Country:US
Mailing Address - Phone:512-477-5645
Mailing Address - Fax:
Practice Address - Street 1:12221 NORTH MOPAC EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758
Practice Address - Country:US
Practice Address - Phone:512-901-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4436207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134602503Medicaid
TX134602508Medicaid
TX134602508Medicaid
TX849742Medicare ID - Type Unspecified
TX8A1488Medicare ID - Type Unspecified