Provider Demographics
NPI:1134755721
Name:JACKSON, MARK WAYNE
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
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 1:8608 MARYS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76116-7624
Mailing Address - Country:US
Mailing Address - Phone:817-420-2929
Mailing Address - Fax:
Practice Address - Street 1:8608 MARYS CREEK DR
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76116-7624
Practice Address - Country:US
Practice Address - Phone:817-420-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108520225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist