Provider Demographics
NPI:1639435019
Name:JACKSON, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 PUEBLO DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-4328
Mailing Address - Country:US
Mailing Address - Phone:214-734-8394
Mailing Address - Fax:972-414-1261
Practice Address - Street 1:2229 PUEBLO DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-4328
Practice Address - Country:US
Practice Address - Phone:214-734-8394
Practice Address - Fax:972-414-1261
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion