Provider Demographics
NPI:1821052903
Name:GASKILL, JACK EDWARD (EDD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:EDWARD
Last Name:GASKILL
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:EDWARD
Other - Last Name:GASKILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EDD
Mailing Address - Street 1:16809 WESTVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78737-9041
Mailing Address - Country:US
Mailing Address - Phone:512-479-3523
Mailing Address - Fax:
Practice Address - Street 1:1215 RED RIVER ST
Practice Address - Street 2:SUITE 448
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1921
Practice Address - Country:US
Practice Address - Phone:512-479-3523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23236103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000T48L2Medicaid
TXP000T48L2Medicaid