Provider Demographics
NPI:1699597849
Name:VALENCIA, JACKSON
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:VALENCIA
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 1:1885 EL PASEO ST
Mailing Address - Street 2:APT 32205
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054
Mailing Address - Country:US
Mailing Address - Phone:281-755-1708
Mailing Address - Fax:
Practice Address - Street 1:7500 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054
Practice Address - Country:US
Practice Address - Phone:713-487-7691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXETN10761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics