MEDICARE: COURTNEY 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	3747P1801X	Personal Care Attendant
2	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1912318429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY JACKSON

Provider Business Mailing Address
First Line	:	4134 WOODMONT DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77045-3330
Country	:	US
Telephone Number	:	713-987-8373
Fax Number	:

Provider Business Practice Location Address
First Line	:	4134 WOODMONT DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77045-3330
Country	:	US
Telephone Number	:	713-987-8373
Fax Number	:

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

Provider Enumeration Date	:	05/19/2014
Last Update Date	:	05/19/2014

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Directions to “ COURTNEY JACKSON ” Practice Location

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