Provider Demographics
NPI:1962479105
Name:JACKSON, FRANK R
Entity Type:Individual
Prefix:DR
First Name:FRANK
Middle Name:R
Last Name:JACKSON
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 1:805 MEDICAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605
Mailing Address - Country:US
Mailing Address - Phone:903-232-8100
Mailing Address - Fax:903-232-8115
Practice Address - Street 1:805 MEDICAL CIRCLE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605
Practice Address - Country:US
Practice Address - Phone:903-232-8100
Practice Address - Fax:903-232-8115
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC9021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80890GMedicare ID - Type Unspecified
TXC17354Medicare UPIN