Healthcare Provider Details

I. General information

NPI: 1689654600
Provider Name (Legal Business Name): JOHN S JACKSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10555 VISTA DEL SOL DR STE 200
EL PASO TX
79925-7943
US

IV. Provider business mailing address

1720 MURCHISON
EL PASO TX
79902
US

V. Phone/Fax

Practice location:
  • Phone: 915-594-5925
  • Fax: 915-594-5926
Mailing address:
  • Phone: 915-533-7465
  • Fax: 915-534-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberJ7998
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: