Provider Demographics
NPI:1689179608
Name:JACKSON, CHRISTOPHER BRYAN
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:BRYAN
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 1:4616 TRIANGLE AVE APT 4110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-3501
Mailing Address - Country:US
Mailing Address - Phone:512-318-6471
Mailing Address - Fax:
Practice Address - Street 1:110 INNER CAMPUS DR
Practice Address - Street 2:COLLEGE OF PHARMACY
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712
Practice Address - Country:US
Practice Address - Phone:512-471-1737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35449390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program