MEDICARE: TOMMORA DENICE JACKSON NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	697480	TX
2	363LP2300X	Primary Care Nurse Practitioner	AP119152	TX

General Provider Information

NPI Number	:	1497075097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOMMORA DENICE JACKSON NP-C

Provider Business Mailing Address
First Line	:	PO BOX 9101
Second Line	:
City	:	COPPELL
State	:	TX
Zip	:	75019-9494
Country	:	US
Telephone Number	:	972-745-7500
Fax Number	:

Provider Business Practice Location Address
First Line	:	7232 NORTH FWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-2481
Country	:	US
Telephone Number	:	817-232-2100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2010
Last Update Date	:	05/14/2015

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