Provider Demographics
NPI:1154435899
Name:JACKSON, PAUL THOMAS JR (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:THOMAS
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 LAMAR AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75462-5124
Mailing Address - Country:US
Mailing Address - Phone:903-739-2888
Mailing Address - Fax:903-739-9643
Practice Address - Street 1:4550 LAMAR AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75462-5124
Practice Address - Country:US
Practice Address - Phone:903-739-2888
Practice Address - Fax:903-739-9643
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096332401Medicaid
TXG32313Medicare UPIN
TX0034BWMedicare ID - Type Unspecified