Provider Demographics
NPI:1689680951
Name:HORTON, JACK E (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:HORTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:1807 W SLAUGHTER LN
Practice Address - Street 2:#490
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6208
Practice Address - Country:US
Practice Address - Phone:512-282-8967
Practice Address - Fax:512-292-5143
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2087208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116361004Medicaid
TX116361005Medicaid
TX116361002Medicaid
TX116361006Medicaid
TXTXB118683Medicare PIN
TX116361006Medicaid
TX370003798Medicare PIN
TXTXB137003Medicare PIN
TX8K0571Medicare PIN