Provider Demographics
NPI:1457350902
Name:JACKSON, JOHN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:JACKSON
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 1:1290 WONDER WORLD DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7969
Mailing Address - Country:US
Mailing Address - Phone:512-393-3325
Mailing Address - Fax:512-393-3328
Practice Address - Street 1:1290 WONDER WORLD DR STE 1100
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7969
Practice Address - Country:US
Practice Address - Phone:512-393-3325
Practice Address - Fax:512-393-3328
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056102207Q00000X
TXE8587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA157509345AMedicaid
GA157509345AMedicaid
TXD66618Medicare UPIN