Provider Demographics
NPI:1598174427
Name:R BRENT JACKSON DO PA
Entity Type:Organization
Organization Name:R BRENT JACKSON DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:210-494-9600
Mailing Address - Street 1:PO BOX 593377
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-0218
Mailing Address - Country:US
Mailing Address - Phone:210-494-9600
Mailing Address - Fax:210-494-9601
Practice Address - Street 1:155 E SONTERRA BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3987
Practice Address - Country:US
Practice Address - Phone:210-494-9600
Practice Address - Fax:210-494-9601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty