MEDICARE: SHI RONDA JACKSON APRN

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	363LF0000X	Family Nurse Practitioner	AP143014	TX

General Provider Information

NPI Number	:	1629729678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHI RONDA JACKSON APRN

Provider Business Mailing Address
First Line	:	18482 KUYKENDAHL RD # 541
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77379-8123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4001 W SAM HOUSTON PKWY N STE 110
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77043-1236
Country	:	US
Telephone Number	:	713-996-0900
Fax Number	:

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

Provider Enumeration Date	:	01/11/2022
Last Update Date	:	01/11/2022

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