MEDICARE: RUSSELL BRENT JACKSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	P5384	TX

General Provider Information

NPI Number	:	1073752879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL BRENT JACKSON D.O.

Provider Business Mailing Address
First Line	:	PO BOX 593377
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-0218
Country	:	US
Telephone Number	:	210-494-9600
Fax Number	:	210-494-9601

Provider Business Practice Location Address
First Line	:	155 E SONTERRA BLVD STE 111
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3988
Country	:	US
Telephone Number	:	210-729-1900
Fax Number	:	210-729-1901

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2009
Last Update Date	:	05/06/2019

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