Provider Demographics
NPI:1356314124
Name:JACKS, RANDAL K (MD)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:K
Last Name:JACKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 LANDA ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-6114
Mailing Address - Country:US
Mailing Address - Phone:830-625-0305
Mailing Address - Fax:830-625-2693
Practice Address - Street 1:774 LANDA ST
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-6114
Practice Address - Country:US
Practice Address - Phone:830-625-0305
Practice Address - Fax:830-625-2693
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D6061Medicare ID - Type Unspecified
C17330Medicare UPIN