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NPI Code Detail

MEDICARE: BAILIE SHANAE JACKSON MD

MEDICARE: BAILIE SHANAE JACKSON MD
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
1390200000XStudent in an Organized Health Care Education/Training ProgramTX

General Provider Information

NPI Number : 1659213122
Entity Type Code : Individual
Provider Name (Legal Business Name) : BAILIE SHANAE JACKSON MD
Provider Business Mailing Address
First Line : 518 COPELAND DR
Second Line :
City : CEDAR HILL
State : TX
Zip : 75104-5062
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 333 N SANTA ROSA
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78207-3108
Country : US
Telephone Number : 210-704-3910
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/06/2026
Last Update Date : 04/06/2026

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Directions to “ BAILIE SHANAE JACKSON MD” Practice Location

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