1114076882 NPI number — MR. ROBERT ALAN JACKSON R.N., FNP-C

Table of content: MR. ROBERT ALAN JACKSON R.N., FNP-C (NPI 1114076882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114076882 NPI number — MR. ROBERT ALAN JACKSON R.N., FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
ROBERT
Provider Middle Name:
ALAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
R.N., FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114076882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4707 TEAKWOOD TRCE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79707-1636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-522-1567
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E BEAUREGARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANGELO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76903-5919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-481-2247
Provider Business Practice Location Address Fax Number:
325-481-2307
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  655208 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP112515 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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