Provider Demographics
NPI:1407685381
Name:JACKSON, BRYAN LEONARD
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:LEONARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8243 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77017-2232
Mailing Address - Country:US
Mailing Address - Phone:727-744-7717
Mailing Address - Fax:
Practice Address - Street 1:9510 N SAM HOUSTON PKWY E
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-2935
Practice Address - Country:US
Practice Address - Phone:281-454-5214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist