MEDICARE: RODERICK JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver

General Provider Information

NPI Number	:	1205194776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RODERICK JACKSON

Provider Business Mailing Address
First Line	:	11826 LONGWOOD GARDEN WAY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77047-4434
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11826 LONGWOOD GARDEN WAY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77047-4434
Country	:	US
Telephone Number	:	713-516-5780
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2012
Last Update Date	:	05/02/2012

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Directions to “ RODERICK JACKSON ” Practice Location

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