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General NPI Number Information
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NPI Number | 1073114518
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Entity Type | Individual
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Provider Name | KESHA JACKSON
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Gender | Female
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Dates
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Enumeration Date | 11/02/2020
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Last Update Date | 11/02/2020
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Provider Practice Location Address
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Address Line | 7451 MCCART AVE
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City | FORT WORTH
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State | TX
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Zip | 76133-7296
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Country | US
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Telephone | 817-361-7284
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Fax |
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Provider Business Mailing Address
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Address Line | 5123 SWAINSONS HAWK LN
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City | GRAND PRAIRIE
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State | TX
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Zip | 75052-3083
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Country | US
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Telephone | 816-309-3628
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 44778
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License Number State | TX
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