Provider Demographics
NPI:1962012138
Name:CRUTCH, JACKSON ISAIAH
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:ISAIAH
Last Name:CRUTCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 E NORTHGATE DR # 245
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-9991
Mailing Address - Country:US
Mailing Address - Phone:256-665-1604
Mailing Address - Fax:
Practice Address - Street 1:8500 N STEMMONS FWY STE 3052
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-3969
Practice Address - Country:US
Practice Address - Phone:256-665-1604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor