Provider Demographics
NPI:1265994313
Name:JACKSON, JERRY SCOTT (HIS)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:SCOTT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 S IH 35 STE A300
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7358
Mailing Address - Country:US
Mailing Address - Phone:512-238-1828
Mailing Address - Fax:512-238-1894
Practice Address - Street 1:2601 S IH 35 STE A300
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7358
Practice Address - Country:US
Practice Address - Phone:512-238-1828
Practice Address - Fax:512-238-1894
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80750237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty