Healthcare Provider Details

I. General information

NPI: 1528846649
Provider Name (Legal Business Name): JACKSON PALMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 HWY 290 E
ELGIN TX
78621-1463
US

IV. Provider business mailing address

1080 HWY 290 E
ELGIN TX
78621-1463
US

V. Phone/Fax

Practice location:
  • Phone: 512-285-4719
  • Fax:
Mailing address:
  • Phone: 512-285-4719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number311511
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: