Individual
SHAUN CHADRICK JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
423 TREELINE PARK, SUITE 325, SAN ANTONIO, TX 78209-2060
(210) 805-9800
Mailing address
45 NE LOOP 410 STE 850, SAN ANTONIO, TX 78216-5824
(210) 805-9800
(210) 805-8770
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
M9372
TX
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
M9372
TX
208VP0000X
Pain Medicine Physician
Primary
M9372
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1984007-01
—
TX
01
—
8L0027
MEDICARE PTAN
TX
01
—
M9372
MEDICAL LICENSE
TX
Enumeration date
05/16/2008
Last updated
06/03/2020
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