Provider Demographics
NPI:1922099977
Name:JACKSON, MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:6100 HARRIS PKWY STE 1200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-6107
Mailing Address - Country:US
Mailing Address - Phone:817-263-3724
Mailing Address - Fax:
Practice Address - Street 1:6100 HARRIS PKWY STE 1200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6107
Practice Address - Country:US
Practice Address - Phone:817-263-3724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285691602Medicaid
TX285691601Medicaid
TX285691601Medicaid
TX378235YKP5Medicare PIN
TX8D9806Medicare PIN
TX378235YKPWMedicare PIN