Provider Demographics
NPI:1053932293
Name:JOHN, JAISON JACOB (DO)
Entity type:Individual
Prefix:
First Name:JAISON
Middle Name:JACOB
Last Name:JOHN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 S 31ST ST # MSAG407Q
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76508-0001
Mailing Address - Country:US
Mailing Address - Phone:254-724-9290
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST # MSAG407Q
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-5302
Practice Address - Country:US
Practice Address - Phone:254-724-9290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10072178207R00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine