Healthcare Provider Details

I. General information

NPI: 1679585087
Provider Name (Legal Business Name): JACK A MAXWELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 FM 2181 STE 100
HICKORY CREEK TX
75065-7636
US

IV. Provider business mailing address

3600 FM 2181 STE 100
HICKORY CREEK TX
75065-7636
US

V. Phone/Fax

Practice location:
  • Phone: 940-497-2204
  • Fax: 940-321-4977
Mailing address:
  • Phone: 940-497-2204
  • Fax: 940-321-4977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG9368
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number2869
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: