=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245977503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAICAERIA TA'RAI JACKSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2022
-----------------------------------------------------
Last Update Date | 05/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6930 FM 1960 RD W
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77069-3702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-836-6085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4526 VERONA HILLS LN
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77449-2990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-978-0460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 1021096
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------