MEDICARE: DR. JOHN ANDREW JACKSON D.D.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D14522	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	784161	OTHER	TX	UNITED CONCORDIA
3	742713545	OTHER	TX	TAX ID

General Provider Information

NPI Number	:	1720162779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ANDREW JACKSON D.D.S.

Provider Business Mailing Address
First Line	:	600 DIVISION AVE
Second Line	:	SUITE E.
City	:	SAN ANTONIO
State	:	TX
Zip	:	78214-1350
Country	:	US
Telephone Number	:	210-924-4279
Fax Number	:	210-924-4270

Provider Business Practice Location Address
First Line	:	600 DIVISION AVE
Second Line	:	SUITE E.
City	:	SAN ANTONIO
State	:	TX
Zip	:	78214-1350
Country	:	US
Telephone Number	:	210-924-4279
Fax Number	:	210-924-4270

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/09/2007

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Directions to “ DR. JOHN ANDREW JACKSON D.D.S.” Practice Location

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