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General NPI Number Information
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NPI Number | 1750867826
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Entity Type | Organization
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Legal Business Name | JACKSON PK, LLC
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Dates
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Enumeration Date | 07/12/2018
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Last Update Date | 07/12/2018
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Provider Practice Location Address
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Address Line | 9701 BRODIE LN STE 202
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City | AUSTIN
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State | TX
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Zip | 78748-6284
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Country | US
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Telephone | 512-326-2520
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Fax |
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Provider Business Mailing Address
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Address Line | 9701 BRODIE LN STE 202
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City | AUSTIN
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State | TX
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Zip | 78748-6284
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Country | US
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Telephone | 512-326-2520
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Fax |
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Authorized Official
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Title or Position | CLINICIAN
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Name | DR. PAUL A SHROGIN
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Credential | DC
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Telephone | 805-478-3760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 13075
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License Number State | TX
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