=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447041520
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENISE T JACKSON PHLEBOTOMIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2025
-----------------------------------------------------
Last Update Date | 05/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6325 ELEPHANT BUTTE
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76708-7509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-245-1208
-----------------------------------------------------
Fax | 254-245-1208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6325 ELEPHANT BUTTE
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76708-7509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-245-1208
-----------------------------------------------------
Fax | 254-245-1208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246Q00000X
-----------------------------------------------------
Taxonomy Name | Pathology Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 246R00000X
-----------------------------------------------------
Taxonomy Name | Pathology Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------