Provider Demographics
NPI:1922150663
Name:J. DON JACKSON JR, MD, PA
Entity Type:Organization
Organization Name:J. DON JACKSON JR, MD, PA
Other - Org Name:ADVANCED SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DON
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:903-723-8210
Mailing Address - Street 1:P O BOX 817
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75802
Mailing Address - Country:US
Mailing Address - Phone:903-723-8210
Mailing Address - Fax:903-723-8310
Practice Address - Street 1:300 WILLOW CREEK PKWY
Practice Address - Street 2:SUITE 200 A
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4421
Practice Address - Country:US
Practice Address - Phone:903-723-8210
Practice Address - Fax:903-723-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178962001Medicaid
TXF45151Medicare UPIN
TX178962001Medicaid