Provider Demographics
NPI:1023088895
Name:JACKSON, PHILLIP (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4609 SCHWERIN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5255
Mailing Address - Country:US
Mailing Address - Phone:361-808-9383
Mailing Address - Fax:361-808-9383
Practice Address - Street 1:4609 SCHWERIN LAKE DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-5255
Practice Address - Country:US
Practice Address - Phone:361-808-9383
Practice Address - Fax:361-808-9383
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4864207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF64754Medicare UPIN