Provider Demographics
NPI:1679994362
Name:JACKSON, FLOYD RAY
Entity Type:Individual
Prefix:
First Name:FLOYD
Middle Name:RAY
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 1:7322 THUROW ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77087-3721
Mailing Address - Country:US
Mailing Address - Phone:832-335-3216
Mailing Address - Fax:832-201-9729
Practice Address - Street 1:7322 THUROW ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77087
Practice Address - Country:US
Practice Address - Phone:832-335-3216
Practice Address - Fax:832-201-9729
Is Sole Proprietor?:No
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174V00000XOther Service ProvidersClinical Ethicist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7311OtherMEDICAID/MEDICARE