Provider Demographics
NPI:1912987660
Name:ACKLEY, JACQUELINE LONGBOTHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:LONGBOTHAM
Last Name:ACKLEY
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 1:118 W CASTLE LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1803
Mailing Address - Country:US
Mailing Address - Phone:210-341-6556
Mailing Address - Fax:
Practice Address - Street 1:118 W CASTLE LN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1803
Practice Address - Country:US
Practice Address - Phone:210-341-6556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7549207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129409206Medicaid
TXP00902937OtherMEDICARE R/R
TX129409206Medicaid
TXP00902937OtherMEDICARE R/R