Provider Demographics
NPI:1699864140
Name:JACKSON, E PENN JR (DDS)
Entity type:Individual
Prefix:DR
First Name:E
Middle Name:PENN
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 E SONTERRA BLVD
Mailing Address - Street 2:#205
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-341-3222
Mailing Address - Fax:210-341-8607
Practice Address - Street 1:155 E SONTERRA BLVD
Practice Address - Street 2:#205
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-341-3222
Practice Address - Fax:210-341-8607
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist