Provider Demographics
NPI:1952739518
Name:JACKSON-BOGLE, LORI (PA)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:
Last Name:JACKSON-BOGLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 RAINFOREST LN
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7272 WURZBACH RD STE 601
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4803
Practice Address - Country:US
Practice Address - Phone:210-615-3483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00313900363AM0700X
NC0010-13228363A00000X
TXPA10582363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical