Provider Demographics
NPI:1134345051
Name:JACKSON CHEN, MD, PA
Entity type:Organization
Organization Name:JACKSON CHEN, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-992-2436
Mailing Address - Street 1:5920 SARATOGA BLVD
Mailing Address - Street 2:320A
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-4103
Mailing Address - Country:US
Mailing Address - Phone:361-992-2436
Mailing Address - Fax:361-980-1133
Practice Address - Street 1:5920 SARATOGA BLVD
Practice Address - Street 2:320A
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-4103
Practice Address - Country:US
Practice Address - Phone:361-992-2436
Practice Address - Fax:361-980-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5082174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1426942Medicaid
TXG70249Medicare UPIN
TX1426942Medicaid