Provider Demographics
NPI:1003878844
Name:RACKHAM, JEANNETTE R (PA)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:R
Last Name:RACKHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5551 CLAY CT
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0705
Mailing Address - Country:US
Mailing Address - Phone:254-702-7665
Mailing Address - Fax:
Practice Address - Street 1:1717 MAIN ST
Practice Address - Street 2:STE 5200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4612
Practice Address - Country:US
Practice Address - Phone:214-712-2775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181488102Medicaid
TX8N9119OtherBLUE SHIELD
TX8N9119OtherBLUE SHIELD
TX8G0532Medicare ID - Type Unspecified
TXTXB165084Medicare PIN