Healthcare Provider Details

I. General information

NPI: 1073752879
Provider Name (Legal Business Name): RUSSELL BRENT JACKSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E SONTERRA BLVD STE 111
SAN ANTONIO TX
78258-3988
US

IV. Provider business mailing address

PO BOX 593377
SAN ANTONIO TX
78259-0218
US

V. Phone/Fax

Practice location:
  • Phone: 210-729-1900
  • Fax: 210-729-1901
Mailing address:
  • Phone: 210-494-9600
  • Fax: 210-494-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberP5384
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: