Provider Demographics
NPI:1689654600
Name:JACKSON, JOHN S (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 MURCHISON
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902
Mailing Address - Country:US
Mailing Address - Phone:915-533-7465
Mailing Address - Fax:915-534-5289
Practice Address - Street 1:10555 VISTA DEL SOL DR STE 200
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7943
Practice Address - Country:US
Practice Address - Phone:915-594-5925
Practice Address - Fax:915-594-5926
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7998207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G03953Medicare UPIN
TX806163Medicare ID - Type Unspecified
TX116426101Medicaid