Provider Demographics
NPI:1912094335
Name:JACKSON, SHARON L (MD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:2716 TIBBETS DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6915
Practice Address - Country:US
Practice Address - Phone:817-571-6644
Practice Address - Fax:817-685-7951
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1835208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140442852Medicaid
TX8462718OtherCIGNA PIN
TX00U87ZOtherBCBSTX GRP PIN
TX140442886Medicaid
TX2195617OtherFIRSTHEATLH PIN
TX1436380OtherUHC PIN
TX5514444OtherCCN PIN
1750369203OtherGRP NPI NUMBER
TX8A3821OtherBCBSTX IND PIN
TXJACS442780OtherCCHP PIN
TX163680501Medicaid
TX5533552OtherAETNA PIN
TXJACS442780OtherCCHP PIN
TX5533552OtherAETNA PIN
TX140442852Medicaid