MEDICARE: TERRI D. JACKSON PA-C

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	363A00000X	Physician Assistant	PA00941	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00051267	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8N4447	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1750381752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRI D. JACKSON PA-C

Provider Business Mailing Address
First Line	:	PO BOX 660599
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75266-0599
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3310 LIVE OAK ST
Second Line	:	YOUTH & FAMILY CENTER
City	:	DALLAS
State	:	TX
Zip	:	75204-6153
Country	:	US
Telephone Number	:	214-266-1257
Fax Number	:	214-266-1258

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

Provider Enumeration Date	:	08/01/2005
Last Update Date	:	09/03/2009

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Directions to “ TERRI D. JACKSON PA-C” Practice Location

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