MEDICARE: VINEY JACKSON

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	3747P1801X	Personal Care Attendant	20201004P	TX
2	3747A0650X	Attendant Care Provider

General Provider Information

NPI Number	:	1548843527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINEY JACKSON

Provider Business Mailing Address
First Line	:	3701 ALTAMESA BLVD # 331652
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-5649
Country	:	US
Telephone Number	:	682-582-3985
Fax Number	:	682-224-2997

Provider Business Practice Location Address
First Line	:	6901 LOMA VISTA DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-6428
Country	:	US
Telephone Number	:	682-253-4807
Fax Number	:	682-224-2997

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

Provider Enumeration Date	:	04/28/2021
Last Update Date	:	04/28/2021

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Directions to “ VINEY JACKSON ” Practice Location

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