Healthcare Provider Details

I. General information

NPI: 1629604111
Provider Name (Legal Business Name): JACKLYN MICHELLE PLATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MEDICAL CENTER DR STE C
DECATUR TX
76234-3844
US

IV. Provider business mailing address

2021 AUDRA LN
DENTON TX
76209-4725
US

V. Phone/Fax

Practice location:
  • Phone: 940-626-2110
  • Fax: 940-626-2113
Mailing address:
  • Phone: 940-395-1659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number728159
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP145409
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: