Provider Demographics
NPI:1861828956
Name:JAACA MANAGEMENT SERVICES LLC
Entity Type:Organization
Organization Name:JAACA MANAGEMENT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANFORD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-521-9861
Mailing Address - Street 1:PO BOX 6008
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5505 NEW COPELAND RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3955
Practice Address - Country:US
Practice Address - Phone:903-521-9861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1992781090OtherINDIVIDUAL NPI