Healthcare Provider Details

I. General information

NPI: 1659852440
Provider Name (Legal Business Name): JACQUETTA JACKSON LSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 TELLURIDE DR
ARLINGTON TX
76001-8529
US

IV. Provider business mailing address

PO BOX 938
ROWLETT TX
75030-0938
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00703
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: