Provider Demographics
NPI:1548240682
Name:JACKSON, PENELOPE AIKIN (MD)
Entity Type:Individual
Prefix:DR
First Name:PENELOPE
Middle Name:AIKIN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PENELOPE
Other - Middle Name:T
Other - Last Name:AIKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2005 ROCKVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049
Mailing Address - Country:US
Mailing Address - Phone:817-579-1005
Mailing Address - Fax:817-579-1093
Practice Address - Street 1:2005 ROCKVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049
Practice Address - Country:US
Practice Address - Phone:817-579-1005
Practice Address - Fax:817-579-1093
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F0721Medicare ID - Type Unspecified
TXH45036Medicare UPIN