MEDICARE: MARK JACKSON P.A.-C

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	363A00000X	Physician Assistant	PA00410	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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922099977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK JACKSON P.A.-C

Provider Business Mailing Address
First Line	:	6100 HARRIS PKWY STE 1200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-6107
Country	:	US
Telephone Number	:	817-263-3724
Fax Number	:

Provider Business Practice Location Address
First Line	:	6100 HARRIS PKWY STE 1200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-6107
Country	:	US
Telephone Number	:	817-263-3724
Fax Number	:

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	10/19/2020

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