Provider Demographics
NPI:1245520808
Name:JACKSON, ROD DEWEY
Entity type:Individual
Prefix:
First Name:ROD
Middle Name:DEWEY
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 1:411 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 4000
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1713
Mailing Address - Country:US
Mailing Address - Phone:214-820-1931
Mailing Address - Fax:214-820-6772
Practice Address - Street 1:411 N WASHINGTON AVE
Practice Address - Street 2:SUITE 4000
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1713
Practice Address - Country:US
Practice Address - Phone:214-820-1931
Practice Address - Fax:214-820-6772
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105104225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand