Provider Demographics
NPI:1902838212
Name:RAINWATER, JACKSON W (BBA)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:W
Last Name:RAINWATER
Suffix:
Gender:M
Credentials:BBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 S NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-6024
Mailing Address - Country:US
Mailing Address - Phone:956-968-6131
Mailing Address - Fax:956-968-1807
Practice Address - Street 1:406 S NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-6024
Practice Address - Country:US
Practice Address - Phone:956-968-6131
Practice Address - Fax:956-968-1807
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50195237700000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1127755-01Medicaid
TX3599474-02Medicaid
TX516433OtherBCBS PROVIDER NUMBER
TX1127755-02Medicaid
TX1127755-03Medicaid