Healthcare Provider Details

I. General information

NPI: 1518508282
Provider Name (Legal Business Name): WHITNEY JACKSON CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 TREELINE PARK STE 325
SAN ANTONIO TX
78209-2087
US

IV. Provider business mailing address

45 NE LOOP 410 STE 850
SAN ANTONIO TX
78216-5824
US

V. Phone/Fax

Practice location:
  • Phone: 210-546-1460
  • Fax:
Mailing address:
  • Phone: 210-805-9800
  • Fax: 210-805-8770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF06192640
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1017686
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: