Healthcare Provider Details

I. General information

NPI: 1447041520
Provider Name (Legal Business Name): JENISE T JACKSON PHLEBOTOMIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6325 ELEPHANT BUTTE
WACO TX
76708-7509
US

IV. Provider business mailing address

6325 ELEPHANT BUTTE
WACO TX
76708-7509
US

V. Phone/Fax

Practice location:
  • Phone: 254-245-1208
  • Fax: 254-245-1208
Mailing address:
  • Phone: 254-245-1208
  • Fax: 254-245-1208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Q00000X
TaxonomyPathology Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246R00000X
TaxonomyPathology Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: