Provider Demographics
NPI:1558665703
Name:JACKSON, MICAH ROY (PA)
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:ROY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 OLYMPIC PLAZA CIR
Mailing Address - Street 2:STE 700
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1954
Mailing Address - Country:US
Mailing Address - Phone:903-592-6000
Mailing Address - Fax:
Practice Address - Street 1:1814 ROSELAND BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4234
Practice Address - Country:US
Practice Address - Phone:903-592-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant