Provider Demographics
NPI:1033778774
Name:JACKSON, DORIS ANN
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19321 PARK ROW APT 1211
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-4892
Mailing Address - Country:US
Mailing Address - Phone:423-645-9932
Mailing Address - Fax:
Practice Address - Street 1:19321 PARK ROW APT 1211
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-4892
Practice Address - Country:US
Practice Address - Phone:423-645-9932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341645164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse