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Individual
MARK JACKSON
Active
Individual
MARK JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.-C
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA00410
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
285691601
—
TX
05
—
285691602
—
TX
Enumeration date
10/31/2005
Last updated
10/19/2020
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