Healthcare Provider Details

I. General information

NPI: 1295562890
Provider Name (Legal Business Name): JOEL JACKSON LPC,CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOEL JACKSON CPO

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 POENISCH DR
CORPUS CHRISTI TX
78412-2708
US

IV. Provider business mailing address

214 POENISCH DR
CORPUS CHRISTI TX
78412-2708
US

V. Phone/Fax

Practice location:
  • Phone: 307-258-6541
  • Fax:
Mailing address:
  • Phone: 307-258-6541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number2206
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number2206
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: