Healthcare Provider Details

I. General information

NPI: 1528825668
Provider Name (Legal Business Name): LASHONDA MICHILL JACKSON-DEAN DM, MBA, CPT, CIVT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11811 EAST FWY STE 325
HOUSTON TX
77029-1982
US

IV. Provider business mailing address

11722 CABOT HILL ST
HOUSTON TX
77044-5500
US

V. Phone/Fax

Practice location:
  • Phone: 832-384-6792
  • Fax: 877-384-2805
Mailing address:
  • Phone: 713-791-2806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberN24104580
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number41B020231215
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number45D2301278
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberN24104580
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: