=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093572026
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRANCE MARQUE JACKSON DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2024
-----------------------------------------------------
Last Update Date | 03/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1035 N HIGHWAY 77 STE 300
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-1397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-366-4348
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3900 COMMERCE ST APT 617
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75226-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-788-6713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 15477
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------