Provider Demographics
NPI:1295354660
Name:JACKSON, JONATHAN (LVN)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 CROWNHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1136
Mailing Address - Country:US
Mailing Address - Phone:210-860-5027
Mailing Address - Fax:
Practice Address - Street 1:8700 CROWNHILL BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1136
Practice Address - Country:US
Practice Address - Phone:210-860-5027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352554164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse