Individual
IVAN JESSE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
3705 MEDICAL PKWY, SUITE 570, AUSTIN, TX 78705-1019
(512) 454-2554
Mailing address
PO BOX 840853, DALLAS, TX 75284-1019
(972) 233-1999
(972) 233-3666
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
796903
TX
367500000X
Certified Registered Nurse Anesthetist
Primary
AP120069
TX
Other
Enumeration date
03/29/2010
Last updated
06/17/2020
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