MEDICARE: MARLISCHA 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	363L00000X	Nurse Practitioner	AP136994	TX
2	363LF0000X	Family Nurse Practitioner	AP136994	TX
3	363LP0200X	Pediatric Nurse Practitioner	AP136994	TX

General Provider Information

NPI Number	:	1801399019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLISCHA JACKSON

Provider Business Mailing Address
First Line	:	21970 BULVERDE RD STE 103
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2179
Country	:	US
Telephone Number	:	210-625-5708
Fax Number	:	888-227-1442

Provider Business Practice Location Address
First Line	:	21970 BULVERDE RD STE 103
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2179
Country	:	US
Telephone Number	:	210-625-5708
Fax Number	:	888-227-1442

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

Provider Enumeration Date	:	03/14/2018
Last Update Date	:	03/04/2026

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Directions to “ MARLISCHA JACKSON ” Practice Location

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