Provider Demographics
NPI:1962734160
Name:J. ANDREW JACKSON, D.D.S. LTD., LLP
Entity type:Organization
Organization Name:J. ANDREW JACKSON, D.D.S. LTD., LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-924-4279
Mailing Address - Street 1:600 DIVISION, SUITE E.
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214
Mailing Address - Country:US
Mailing Address - Phone:210-924-4279
Mailing Address - Fax:210-924-4270
Practice Address - Street 1:600 DIVISION, SUITE E.
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214
Practice Address - Country:US
Practice Address - Phone:210-924-4279
Practice Address - Fax:210-924-4270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX145221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX651906OtherPMI DELTA CARE
TX784161OtherUNITED CONCORDIA
TX56539501OtherAETNA
TX1306300-05Medicaid