Individual
JACKSON SU
Active
Individual
JACKSON SU
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
M0582
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
177480401
—
TX
01
—
177480402
MEDICAID-CSHCN
TX
01
—
8S0050
BCBS
TX
Enumeration date
10/04/2006
Last updated
02/22/2021
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