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General NPI Number Information
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NPI Number | 1407318223
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Entity Type | Individual
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Provider Name | RYAN C JACKSON MD
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Gender | Male
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Dates
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Enumeration Date | 04/01/2019
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Last Update Date | 07/07/2025
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Provider Practice Location Address
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Address Line | 1600 CENTRAL DR STE 310
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City | BEDFORD
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State | TX
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Zip | 76022-6029
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Country | US
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Telephone | 817-267-8470
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Fax |
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Provider Business Mailing Address
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Address Line | 950 E STATE HIGHWAY 114 STE 200
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City | SOUTHLAKE
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State | TX
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Zip | 76092-5261
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Country | US
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Telephone | 214-424-2200
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | V8652
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License Number State | TX
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