Provider Demographics
NPI:1063580843
Name:GREG L JACKSON
Entity type:Organization
Organization Name:GREG L JACKSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-380-2065
Mailing Address - Street 1:4386 SUNBELT DR
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001
Mailing Address - Country:US
Mailing Address - Phone:972-380-2065
Mailing Address - Fax:972-380-9488
Practice Address - Street 1:4386 SUNBELT DR
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001
Practice Address - Country:US
Practice Address - Phone:972-380-2065
Practice Address - Fax:972-380-9488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010118001OtherMEDICAID CCP
TX011564401Medicaid
TX0519596OtherBLUE CROSS BLUE SHIELD
TX0519596OtherBLUE CROSS BLUE SHIELD