Provider Demographics
NPI:1720162779
Name:JACKSON, JOHN ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDREW
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 1:600 DIVISION AVE
Mailing Address - Street 2:SUITE E.
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-1350
Mailing Address - Country:US
Mailing Address - Phone:210-924-4279
Mailing Address - Fax:210-924-4270
Practice Address - Street 1:600 DIVISION AVE
Practice Address - Street 2:SUITE E.
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214-1350
Practice Address - Country:US
Practice Address - Phone:210-924-4279
Practice Address - Fax:210-924-4270
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD145221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1306300-05Medicaid
TX784161OtherUNITED CONCORDIA
TX742713545OtherTAX ID