Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208100000X | Physical Medicine & Rehabilitation Doctor | M9372 | TX |
N | 2081P2900X | Pain Medicine | M9372 | TX |
NPI | 1407013691 |
---|---|
Provider Name | Shaun Chadrick Jackson |
First Address | San Antonio, TX 78216-5824 |
Second Address | San Antonio, TX 78209-2060 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/05/2008 |
Last Update Date | 03/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1984007-01 | (05) | TX |
8L0027 | MEDICARE PTAN (01) | TX |
M9372 | MEDICAL LICENSE (01) | TX |