Provider Demographics
NPI:1689832768
Name:JACKSON, RANDY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:ALAN
Last Name:JACKSON
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 1:7203 BRINGLE RDG
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5460
Mailing Address - Country:US
Mailing Address - Phone:903-306-1185
Mailing Address - Fax:
Practice Address - Street 1:2602 SAINT MICHAEL DR
Practice Address - Street 2:SUITE 205
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2387
Practice Address - Country:US
Practice Address - Phone:903-614-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200544901Medicaid
TX8BU284OtherBCBS OF TEXAS
AR176329001Medicaid
OK200235880 AMedicaid
AR176329001Medicaid