Provider Demographics
NPI:1154528263
Name:JACKSON, GARY WAYNE (PA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 S. COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336
Mailing Address - Country:US
Mailing Address - Phone:806-864-3141
Mailing Address - Fax:806-894-7094
Practice Address - Street 1:1804 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:LEVELLAND
Practice Address - State:TX
Practice Address - Zip Code:79336-6507
Practice Address - Country:US
Practice Address - Phone:806-894-3141
Practice Address - Fax:806-894-7094
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant