Provider Demographics
NPI:1336375138
Name:JACKSON, BRENT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 STATE HIGHWAY 43 E
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652-9106
Mailing Address - Country:US
Mailing Address - Phone:903-657-3139
Mailing Address - Fax:
Practice Address - Street 1:1910 STATE HIGHWAY 43 E
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-9106
Practice Address - Country:US
Practice Address - Phone:903-657-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist