MEDICARE: MS. SANDRA DENISE JACKSON

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	332B00000X	Durable Medical Equipment & Medical Supplies	7615987412143	TX
2	374U00000X	Home Health Aide	7615987412143	TX

General Provider Information

NPI Number	:	1619118288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA DENISE JACKSON

Provider Business Mailing Address
First Line	:	4303 HERRIDGE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77022-3944
Country	:	US
Telephone Number	:	281-904-4081
Fax Number	:

Provider Business Practice Location Address
First Line	:	4303 HERRIDGE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77022-3944
Country	:	US
Telephone Number	:	281-904-4081
Fax Number	:

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

Provider Enumeration Date	:	03/11/2009
Last Update Date	:	03/11/2009

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Directions to “ MS. SANDRA DENISE JACKSON ” Practice Location

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