Healthcare Provider Details

I. General information

NPI: 1881805034
Provider Name (Legal Business Name): MARNIE JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2007
Last Update Date: 11/22/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 S ARROYO BLVD, PO BOX 529
RIO HONDO TX
78583-4165
US

IV. Provider business mailing address

606 ARROYO BLVD BOX 529
RIO HONDO TX
78583-4165
US

V. Phone/Fax

Practice location:
  • Phone: 956-226-8389
  • Fax: 956-630-6643
Mailing address:
  • Phone: 956-226-8389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberN0852
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberN0852
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN0852
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: