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General NPI Number Information
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NPI Number | 1992003016
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Entity Type | Organization
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Legal Business Name | MARTIN JACKSON DPM PSC
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Dates
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Enumeration Date | 03/14/2011
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Last Update Date | 03/14/2011
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Provider Practice Location Address
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Address Line | 1675 REPUBLIC PKWY STE 101
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City | MESQUITE
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State | TX
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Zip | 75150-6902
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Country | US
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Telephone | 214-478-8483
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Fax | 714-903-7801
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Provider Business Mailing Address
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Address Line | PO BOX 797512
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City | DALLAS
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State | TX
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Zip | 75379-7512
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Country | US
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Telephone | 214-478-8483
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Fax | 714-903-7801
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Authorized Official
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Title or Position | OWNER
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Name | MARTIN JACKSON
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Credential |
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Telephone | 214-478-8483
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 1239
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License Number State | TX
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