MEDICARE: JEANNETTE R RACKHAM PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA03203	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8N9119	OTHER	TX	BLUE SHIELD

General Provider Information

NPI Number	:	1003878844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNETTE R RACKHAM PA

Provider Business Mailing Address
First Line	:	5551 CLAY CT
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-0705
Country	:	US
Telephone Number	:	254-702-7665
Fax Number	:

Provider Business Practice Location Address
First Line	:	1717 MAIN ST
Second Line	:	STE 5200
City	:	DALLAS
State	:	TX
Zip	:	75201-4612
Country	:	US
Telephone Number	:	214-712-2775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	12/26/2012

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Directions to “ JEANNETTE R RACKHAM PA” Practice Location

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