Provider Demographics
NPI:1396773750
Name:JACKSON, WARREN T (PHD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 GASTON AVE
Mailing Address - Street 2:1155 WADLEY TOWER
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-820-5516
Mailing Address - Fax:214-820-5518
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:1155 WADLEY TOWER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-820-5516
Practice Address - Fax:214-820-5518
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33275103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS13155OtherVIVA
AL051033357OtherBLUE CROSS
AL330000005OtherMEDICAID REHAB
AL009975575Medicaid
AL000033357Medicare ID - Type Unspecified
AL051503603OtherBC FEDERAL EHBP