Provider Demographics
NPI:1700884947
Name:JACKSON, GARY L (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2732
Mailing Address - Country:US
Mailing Address - Phone:903-735-9802
Mailing Address - Fax:903-735-9806
Practice Address - Street 1:4100 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2732
Practice Address - Country:US
Practice Address - Phone:903-735-9802
Practice Address - Fax:903-735-9806
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2014-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231425367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83137COtherBLUE CROSS
AR84320OtherBLUE CROSS
TX002851601Medicaid
AR117307701Medicaid
TX002851601Medicaid
TX83137COtherBLUE CROSS