Basic Information
Provider Information | |||||||||
NPI: | 1326417015 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | ANA | ||||||||
MiddleName: | LOUISA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.C. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VALLEJO | ||||||||
OtherFirstName: | ANA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 700688 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782700688 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2103183007 | ||||||||
FaxNumber: | 2104680682 | ||||||||
Practice Location | |||||||||
Address1: | 5445 BASSWOOD BLVD STE 650 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761374447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004046050 | ||||||||
FaxNumber: | 8663133397 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2015 | ||||||||
LastUpdateDate: | 03/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 12741 | TX | Y |   | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | 12741 | 01 | TX | TEXAS BOARD OF CHIROPRACTIC | OTHER |