Provider Demographics
NPI:1871648253
Name:JACKSON, JAMES RICHARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RICHARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13310 LEOPARD ST STE 6
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410
Mailing Address - Country:US
Mailing Address - Phone:361-241-2722
Mailing Address - Fax:
Practice Address - Street 1:3403 S PADRE ISLAND DR STE 301
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-2925
Practice Address - Country:US
Practice Address - Phone:361-445-3969
Practice Address - Fax:361-445-3970
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D2135Medicare UPIN