MEDICARE: CHARLOTTE LYNETTA 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	163WP0200X	Pediatric Registered Nurse	253464	TX

General Provider Information

NPI Number	:	1740843507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE LYNETTA JACKSON

Provider Business Mailing Address
First Line	:	7610 ASHMOLE LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77088-5658
Country	:	US
Telephone Number	:	713-898-8337
Fax Number	:

Provider Business Practice Location Address
First Line	:	7610 ASHMOLE LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77088-5658
Country	:	US
Telephone Number	:	713-898-8337
Fax Number	:

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

Provider Enumeration Date	:	04/17/2019
Last Update Date	:	04/17/2019

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