Healthcare Provider Details

I. General information

NPI: 1154528263
Provider Name (Legal Business Name): GARY WAYNE JACKSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 COLLEGE AVE
LEVELLAND TX
79336-6507
US

IV. Provider business mailing address

1805 S. COLLEGE AVE
LEVELLAND TX
79336
US

V. Phone/Fax

Practice location:
  • Phone: 806-894-3141
  • Fax: 806-894-7094
Mailing address:
  • Phone: 806-864-3141
  • Fax: 806-894-7094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02551
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: