Provider Demographics
NPI:1851387625
Name:JACKSON, RICHARD H (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:H
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 1:8230 WALNUT HILL LN
Mailing Address - Street 2:STE 220
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4482
Mailing Address - Country:US
Mailing Address - Phone:214-750-3646
Mailing Address - Fax:214-265-9378
Practice Address - Street 1:8230 WALNUT HILL LN
Practice Address - Street 2:STE 220
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4482
Practice Address - Country:US
Practice Address - Phone:214-750-3646
Practice Address - Fax:214-265-9378
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1682207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104146902Medicaid
TX84415FMedicare ID - Type UnspecifiedPROVIDER NUMBER
TX104146902Medicaid