Healthcare Provider Details

I. General information

NPI: 1902110521
Provider Name (Legal Business Name): MS. JUANITA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11000 CORPORATE CENTRE DR STE 100
HOUSTON TX
77041-5167
US

IV. Provider business mailing address

11000 CORPORATE CENTRE DR STE 100
HOUSTON TX
77041-5167
US

V. Phone/Fax

Practice location:
  • Phone: 713-983-2082
  • Fax:
Mailing address:
  • Phone: 713-983-2082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number106198
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: