Provider Demographics
NPI:1669725529
Name:JACKSON, ASIA N (DPM)
Entity type:Individual
Prefix:
First Name:ASIA
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 EUREKA ST STE C
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-6521
Mailing Address - Country:US
Mailing Address - Phone:817-596-5077
Mailing Address - Fax:817-598-0673
Practice Address - Street 1:750 EUREKA ST STE C
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-6521
Practice Address - Country:US
Practice Address - Phone:817-596-5077
Practice Address - Fax:817-598-0673
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPR282213ES0103X
TX2155213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery