Provider Demographics
NPI:1053080622
Name:JACKSON, JACQUELYN DENISE (RN, BSN, MSN-PH, AN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, BSN, MSN-PH, AN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 RIDGE OAK DR
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-5031
Mailing Address - Country:US
Mailing Address - Phone:469-350-3557
Mailing Address - Fax:
Practice Address - Street 1:650 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:FT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-4030
Practice Address - Country:US
Practice Address - Phone:785-239-7727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR0787192083P0901X, 163WC0400X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse