Healthcare Provider Details

I. General information

NPI: 1073192530
Provider Name (Legal Business Name): CODY BLAKE JACKSON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2021
Last Update Date: 08/28/2022
Certification Date: 08/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12704 BAMMEL NORTH HOUSTON ROAD
HOUSTON TX
77066-7706
US

IV. Provider business mailing address

12704 BAMMEL NORTH HOUSTON RD
HOUSTON TX
77066-4001
US

V. Phone/Fax

Practice location:
  • Phone: 713-461-2915
  • Fax:
Mailing address:
  • Phone: 318-235-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1073192530
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: