Provider Demographics
NPI:1013189901
Name:JACKSON, CASEY YATES (PA)
Entity Type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:YATES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:CASEY
Other - Middle Name:RAY
Other - Last Name:YATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:18535 FM 1488 RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-2700
Mailing Address - Country:US
Mailing Address - Phone:281-789-7065
Mailing Address - Fax:866-469-6650
Practice Address - Street 1:18535 FM 1488 RD
Practice Address - Street 2:SUITE 210
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-2700
Practice Address - Country:US
Practice Address - Phone:281-789-7065
Practice Address - Fax:866-469-6650
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant