Provider Demographics
NPI:1760738355
Name:JACKSON, ANDREW A (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:A
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:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:9180 PINECROFT DR STE 600
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380
Practice Address - Country:US
Practice Address - Phone:281-296-0365
Practice Address - Fax:281-298-8907
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0464207R00000X, 207RX0202X, 207RH0003X
TXBP1-0040195390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX335913503Medicaid